Coping with Violence in Mental Health Care Settings: Patient and Staff Member Perspectives on De-escalation Practices

Development and evaluation of a de-escalation training intervention in adult acute and forensic units: the EDITION systematic review and feasibility trial

Background

Containment (e.g. physical restraint and seclusion) is used frequently in mental health inpatient settings. Containment is associated with serious psychological and physical harms. De-escalation (psychosocial techniques to manage distress without containment) is recommended to manage aggression and other unsafe behaviours, for example self-harm. All National Health Service staff are trained in de-escalation but there is little to no evidence supporting training's effectiveness.

Objectives

Objectives were to: (1) qualitatively investigate de-escalation and identify barriers and facilitators to use across the range of adult acute and forensic mental health inpatient settings; (2) co-produce with relevant stakeholders an intervention to enhance de-escalation across these settings; (3) evaluate the intervention's preliminary effect on rates of conflict (e.g. violence, self-harm) and containment (e.g. seclusion and physical restraint) and understand barriers and facilitators to intervention effects.

Design

Intervention development informed by Experience-based Co-design and uncontrolled pre and post feasibility evaluation. Systematic reviews and qualitative interviews investigated contextual variation in use and effects of de-escalation. Synthesis of this evidence informed co-design of an intervention to enhance de-escalation. An uncontrolled feasibility trial of the intervention followed. Clinical outcome data were collected over 24 weeks including an 8-week pre-intervention phase, an 8-week embedding and an 8-week post-intervention phase.

Setting

Ten inpatient wards (including acute, psychiatric intensive care, low, medium and high secure forensic) in two United Kingdom mental health trusts.

Participants

In-patients, clinical staff, managers, carers/relatives and training staff in the target settings.

Interventions

Enhancing de-escalation techniques in adult acute and forensic units: Development and evaluation of an evidence-based training intervention (EDITION) interventions included de-escalation training, two novel models of reflective practice, post-incident debriefing and feedback on clinical practice, collaborative prescribing and ward rounds, practice changes around admission, shift handovers and the social and physical environment, and sensory modulation and support planning to reduce patient distress.

Main outcome measures

Outcomes measured related to feasibility (recruitment and retention, completion of outcome measures), training outcomes and clinical and safety outcomes. Conflict and containment rates were measured via the Patient-Staff Conflict Checklist. Clinical outcomes were measured using the Attitudes to Containment Measures Questionnaire, Attitudes to Personality Disorder Questionnaire, Violence Prevention Climate Scale, Capabilities, Opportunities, and Motivation Scale, Coercion Experience Scale and Perceived Expressed Emotion in Staff Scale.

Results

Completion rates of the proposed primary outcome were very good at 68% overall (excluding remote data collection), which increased to 76% (excluding remote data collection) in the post-intervention period. Secondary outcomes had high completion rates for both staff and patient respondents. Regression analyses indicated that reductions in conflict and containment were both predicted by study phase (pre, embedding, post intervention). There were no adverse events or serious adverse events related to the intervention.

Conclusions

Intervention and data-collection procedures were feasible, and there was a signal of an effect on the proposed primary outcome.

Limitations

Uncontrolled design and self-selecting sample.

Future work

Definitive trial determining intervention effects.

Trial registration

This trial is registered as ISRCTN12826685 (closed to recruitment).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/101/02) and is published in full in Health Technology Assessment; Vol. 28, No. 3. See the NIHR Funding and Awards website for further award information.

Context

Conflict (a term used to describe a range of potentially unsafe events including violence, self-harm, rule-breaking, medication refusal, illicit drug and alcohol use and absconding) in mental health settings causes serious physical and psychological harm. Containment interventions which are intended to minimise harm from violence (and other conflict behaviours) such as restraint, seclusion and rapid tranquilisation can result in serious injuries to patients and, occasionally, death. Involvement in physical restraint is the most common cause of serious physical injury to National Health Service mental health staff in the United Kingdom. Violence to staff results in substantial costs to the health service in sickness and litigation payments. Containment interventions are also expensive (e.g. physical restraint costs mental health services £6.1 million and enhanced observations £88 million per annum). Despite these harms, recent findings indicate containment interventions such as seclusion and physical restraint continue to be used frequently in mental health settings. Clinical trials have demonstrated that interventions can reduce containment without increasing violence and other conflict behaviours (e.g. verbal aggression, self-harm). Substantial cost-savings result from reducing containment use. De-escalation, as an intervention to manage aggression and potential violence without restrictive practices, is a core intervention. 'De-escalation' is a collective term for a range of psychosocial techniques designed to reduce distress and anger without the need to use 'containment' interventions (measures to prevent harm through restricting a person's ability to act independently, such as physical restraint and seclusion). Evidence indicates that de-escalation involves ensuring conditions for safe intervention and effective communication are established, clarifying and attempting to resolve the patient's concern, conveyance of respect and empathy and regulating unhelpful emotions such as anxiety and anger. Despite featuring prominently in clinical guidelines and training policy domestically and internationally and being a component of mandatory National Health Service training, there is no evidence-based model on which to base training. A systematic review of de-escalation training effectiveness and acceptability conducted in 2015 concluded: (1) no model of training has demonstrated effectiveness in a sufficiently rigorous evaluation, (2) the theoretical underpinning of evaluated models was often unclear and (3) there has been inadequate investigation of the characteristics of training likely to enhance acceptability and uptake. Despite all National Health Service staff being trained in de-escalation there have been no high-quality trials evaluating the effectiveness and cost-effectiveness of training. Feasibility studies are needed to establish whether it is possible to conduct a definitive trial that can determine the clinical, safety and cost-effectiveness of this intervention.

Mental Health Nurses Who Experience Disabilities: Adapting to Workplace Barriers

Mental health nurses with disabilities experience discrimination and issues with inclusion and accessibility. Ten mental health nurses who self-identified with a disability were interviewed using interpretive description to gain insight into their experiences and to better understand practices that promote inclusion. Participants discussed challenges associated with the mental healthcare system, the need to adapt, and the importance of support and feeling accepted. To improve accessibility and inclusion of mental health nurses, the system requires increased flexibility. This would benefit all nurses and those who are cared for by them.

Sustaining a therapeutic environment within mental health in-patient settings during COVID-19. Results of a Delphi study

AIM

Develop a strengths-based, person-centred, trauma-informed and recovery-oriented framework to mitigate any potential increase in conflict resulting from the implementation of C19 restrictions.

BACKGROUND

Guidance addressing the unique challenges posed by Covid-19 within mental health in-patient settings, including how to support those whose distress may present as behaviour that challenges including violence and self-harm, remains urgently needed.

METHODOLOGY/APPROACH

A Delphi design involving four iterative stages was adopted. Stage 1 involved a review and synthesis of COVID-19-related public health and ethical guidance and a narrative literature review. A formative operational framework was then developed. Stage 2 sought to establish the face validity of the framework through engagement with frontline and senior staff in mental health services in Ireland, Denmark and Netherlands. Stage 3 investigated the content validity of the final framework through a plenary presentation and discussion of the framework at a scientific symposium of the European Violence in Psychiatric Research Group (EViPRG, 2020). Stage 4 sought expert appraisal of the framework using a structured evaluation completed by a panel of eighteen multidisciplinary experts from nine countries, including four academics, six clinicians and eight holding dual clinical/academic appointments to assess content validity.

RESULTS

The guidance adopts the widely advocated approach to support those whose distress may present as behaviour services find challenging in identifying the need for primary, secondary, tertiary and recovery measures. It emphasizes person-centred care while integrating specific Covid-19 public health requirements into service planning. It also aligns with contemporary best practice in in-patient mental health care, incorporating the principles of Safewards, the core values of trauma-informed care, and an explicit on recovery.

CONCLUSION

The guidance developed has face and content validity.

Emergency Nurses' Care of Psychiatric Patients

OBJECTIVE

The volume of patients with mental illness presenting to the emergency department (ED) has been increasing in recent years, yet many ED nurses hold stigmatized attitudes and behaviors about patients with mental illness, creating barriers to therapeutic care. At the same time, there has been an increase in workplace violence (WPV) against nurses. Fortunately, resilience helps nurses manage their response to WPV and continue to provide therapeutic care. Although research has considered many barriers to the therapeutic care of patients with mental illness in the ED, the variables of stigma, resilience, and the experience of WPV have not been considered in relation to behavioral care competence and work performance, which is the purpose of this study.

METHODS

A survey consisting of the Brief Resilience Scale, the Individual Work Performance Questionnaire, the Behavioral Healthcare Competency (BHCC) survey, the Opening Minds Scale for Healthcare Providers, and open-ended questions about WPV were used to collect data. Independent t-tests were run between scale scores and categorical descriptive data. Correlations were run between scale scores and continuous descriptive data.

RESULTS

Over half (60%) had experienced a personal injury from WPV. Higher behavioral competence scores were associated with lower stigma and higher contextual work performance. Nurses who experienced a WPV injury had higher mean BHCC and higher contextual work performance scores.

CONCLUSIONS

WPV may be an impetus for nurses to improve their practice in behavioral health and working as part of a team.

Incidents related to safety in mental health facilities in Kenya

BACKGROUND

Both patients and health care providers working in mental health facilities witness high rates of incidents that have the potential to jeopardize their safety. Despite this, there are few studies that have documented the kind of incidents that are experienced, or explored the potential contributors to these incidents, and solutions that would result in better safety. This study explored various types of safety related incidents occurring in mental facilities in Kenya, perceived contributing factors, and recommendations for improve.

METHODS

This qualitative descriptive study was carried out between December 2019 - February 2020. It included 28 mental health staff across 14 mental health unit spread across the country.

RESULTS

All the participants reported having personally experienced an incident that threatened their safety or that of the patients. Most of the respondents (24/26. 91.67%) admitted to have experienced verbal aggression while 54.17%, (n = 24) had experienced physical assault. Participating health care workers attributed the safety incidents to poor infrastructure, limited human resources, and inadequate medication to calm down agitated patients. Suggested solutions to improve patient safety included; improving surveillance systems, hiring more specialized healthcare workers, and provision of adequate supplies such as short-acting injectable psychotropic.

CONCLUSION

Incidents that threaten patient and staff safety are common in mental health facilities in Kenya. There is need to strengthen staff capacity and reporting mechanisms, as well as invest in infrastructural improvements, to safeguard patient and staff safety in mental health facilities in Kenya.

Experiences of preventing violence in two high-risk sectors: A qualitative study of front-line workers

BACKGROUND

Exposure to workplace violence is associated with physical and/or psychological trauma. Despite its significant impact, little is known about front-line workers' experiences of preventing workplace violence.

OBJECTIVE

This study aimed to identify what workers identify as important to preventing workplace conflicts from escalating into violence.

METHODS

We conducted seventeen qualitative focus-group interviews with fifty-eight workers at the Danish Prison and Probation Service and psychiatric hospitals. We applied thematic analysis to identify types of violence-prevention practices, and prerequisites for successfully preventing workplace violence.

RESULTS

We identified two main categories of violence-prevention practices, and one main category of prerequisites for violence-prevention practices. Main category A), "the individual worker's violence-prevention practices" included the sub-categories, 1) identify the causes of workplace violence and potentially violent situations, 2) establish relationships, state rules, and set clear boundaries and 3) display empathy and communicate respectfully. Main category B), "collaborative practices for preventing workplace violence" included 4) communicate with co-workers, and share information and observations, 5) coordinate work, avoid being played off against colleagues, and support colleagues. Main category C), "prerequisites for violence-prevention practices" included 6) managing one's emotions, and 7) having sufficient time to do the job, and being a part of a stable team, whose members know each other and the inmates/patients".

CONCLUSION

This study contributes to a better understanding of the interplay among individual, collaborative, and contextual aspects of preventing workplace violence. We believe that an increased understanding of the complexity of preventing workplace violence in high-risk sectors is useful when designing comprehensive violence-prevention strategies.

The aggressive patient experiences of healthcare professionals exposed to physical violence in a psychiatric clinic: A phenomenological study

PURPOSE

This study investigated the experiences of healthcare professionals, exposed to physical violence, related to aggressive patients at a psychiatry service.

DESIGN AND METHODS

The qualitative study sample consisted of a total of 21 healthcare professionals. The data were collected through in-depth interviews. An inductive qualitative content analysis was used to analyze the data.

FINDINGS

Three themes, the effects of warning signs of violence, clinical management of violence, and effects of violence, and 13 sub-themes were determined.

PRACTICE IMPLICATIONS

The effects of physical violence on healthcare professionals can be seen and will contribute to planning in this regard.

Relationship between nurses' use of verbal de-escalation and mechanical restraint in acute inpatient mental health care: a retrospective study

Although the use of verbal de-escalation in nursing has been shown to be an effective tool for controlling agitation and avoiding mechanical restraint, there is scarce evidence supporting the use of de-escalation by nurses and factors related to the patients who ultimately receive mechanical restraint. This retrospective study sought to examine the relationship between the use of verbal de-escalation by nurses and the clinical profile of patients who had received mechanical restraint at an acute mental health unit. This study analysed the records of patients who had received mechanical restraint between the years 2012 and 2019. A bivariate analysis was initially performed, followed by multiple logistic regression analysis. A total of 493 episodes of restraint were recorded. Of these, in almost 40% of cases, no prior use of verbal de-escalation was noted. The factors associated with the use of verbal de-escalation by nurses were patients with a history of restraint episodes and patients who previously had been administered medication. Furthermore, episodes of mechanical restraint that occurred later during the admission were also associated with the use of de-escalation. These findings confirm the relevance of early nurse interventions. Consequently, it is important to establish an adequate therapeutic relationship from the start of hospitalization to facilitate getting to know the patient and to enable the timely use of verbal de-escalation, thus avoiding the use of mechanical restraint.

Strategies for the Prevention of Violence in Institutional Care: A Qualitative Interview Study With Ward Managers

BACKGROUND

The presence of violence within psychiatric and residential settings remains a challenge. Research on this problem has often focused on describing violence prevention strategies from either staffs' or service users' perspectives, and the views of ward managers has been largely overlooked. The aim of the present study was therefore to identify ward managers' strategies to prevent violence in institutional care, focusing on safety and values.

METHODS

Data were collected using semi-structured interviews with 12 ward managers who headed four different types of psychiatric wards and two special residential homes for adolescents. Qualitative content analysis was applied, first using a deductive approach, in which quotes were selected within a frame of primary, secondary, and tertiary prevention, then by coding using an inductive approach to create themes and subthemes.

RESULTS

Ward managers' strategies were divided into the four following themes: (1) Balancing being an active manager with relying on staff's abilities to carry out their work properly while staying mostly in the background; (2) Promoting value awareness and non-coercive practices in encounters with service users by promoting key values and adopting de-escalation techniques, as well as focusing on staff-service user relationships; (3) Acknowledging and strengthening staff's abilities and competence by viewing and treating staff as a critical resource for good care; and (4) Providing information and support to staff by exchanging information and debriefing them after violent incidents.

CONCLUSIONS

Ward managers described ethical challenges surrounding violence and coercive measures. These were often described as practical problems, so there seems to be a need for a development of higher ethical awareness based on a common understanding regarding central ethical values to be respected in coercive care. The ward managers seem to have a high awareness of de-escalation and the work with secondary prevention, however, there is a need to develop the work with primary and tertiary prevention. The service user group or user organizations were not considered as resources in violence prevention, so there is a need to ensure that all stakeholders are active in the process of creating violence prevention strategies.

General Hospital Agitation Management Under the Lens of Leadership Theory and Health Care Team Best Practices Using TeamSTEPPS

BACKGROUND

Acute agitation management is an emergency clinical intervention, often presenting acute danger to patients and medical staff. Unlike many other emergency clinical interventions, acute agitation management lacks a substantial evidence base regarding leadership and teamwork best practices. The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) framework is a comprehensive strategy for improving health care outcomes in acute clinical situations.

OBJECTIVE

Practical application of TeamSTEPPS frameworks in team-based acute agitation management in the medical setting.

METHODS

A literature review was performed from January 1990 to March 2021 for verbal de-escalation in acute agitation management, leadership and teamwork in psychiatry and medicine, and TeamSTEPPS.

RESULTS

No literature was found that applied TeamSTEPPS for acute agitation management in the general medical unit context although limited application has been trialed in the inpatient psychiatric context. The verbal de-escalation literature describes applicable content including conflict management approaches, communication strategies, security presence management, modeling therapeutic behavior, and debriefing strategies. Several articles were found regarding a rapid response team model for acute agitation management and describing handoff tools in psychiatric care contexts. Translation of the TeamSTEPPS approach provided many additional approaches for operation of a rapid response team in acute agitation management.

CONCLUSIONS

The leadership and teamwork best practices in TeamSTEPPS provide a clear and actionable framework for team-based acute agitation management as an emergency clinical intervention.

Occurrence of workplace violence and the psychological consequences of it among nurses working in psychiatric outpatient settings

WHAT IS KNOWN ON THE SUBJECT?: There is a scarcity of studies concerning violence in psychiatric outpatient settings in the 2010s in spite of the deinstitutionalization of psychiatric services. Previous research on violence in psychiatric outpatient settings has failed to consider the association between the psychological consequences of violence, exposures to violence and background factors. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: It has been known for some time that exposures to violence are harmful for psychiatric inpatient nurses; the paper demonstrates that psychiatric outpatient nurses are also at risk. The psychological consequences of exposure to violence are highly individualized and influenced by background factors. Nurses who face harassment have a greater risk of suffering psychological symptoms. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: De-escalation interventions should be implemented in psychiatric outpatient settings. Organizations should consider the possibility of internal violence occurring when planning preventive interventions to manage and reduce workplace violence. Education targeted at violence prevention, management and debriefing should be organized systematically in psychiatric outpatient units and be taken into consideration in the mental health nursing curriculum. ABSTRACT: Introduction There is a scarcity of studies concerning violence and its consequences in psychiatric outpatient setting. Aim This study aimed to explore the occurrence of workplace violence and the psychological consequences of exposure to violence among nurses working in psychiatric outpatient settings. Method Research followed a cross-sectional survey design. Data were collected with the VIA-Q instrument. Results During the 12 months prior to the study, nurses (n = 181) had most often experienced psychological violence, with fatigue being the most common consequence. Harassment most often caused feelings of violated integrity, whereas physical violence most often caused insomnia. Significant relationships between exposure to violence and psychological consequences were identified. Discussion Workplace violence can manifest in a broad array of psychological symptoms and be harmful for nurses in psychiatric outpatient settings. It is important to discuss the subject of workplace violence and its place in the nursing curriculum and to reflect on how nurses are educated and trained to face violence in psychiatric nursing. Implications for Practice De-escalation interventions should be implemented in psychiatric outpatient settings. Organizations should take steps to abolish internal violence. Nurses need appropriate education in order to prepare them to manage workplace violence.

A Quality Improvement Project on Agitation Management in the Emergency Department

INTRODUCTION

Agitation is common in the emergency department. When agitation is not detected early, patients can become aggressive and violent, potentially leading to restraint use and subsequent injury. The goals of the project were early detection and management of patient agitation, reduction of restraint use in the emergency department, and determination of the usability of the Behavioral Activity Rating Scale.

METHODS

This quality improvement project was assessed using a pre- and posttest single unit design, comparing 4 months of postimplementation data to historic controls at the same time of year in the previous year. The intervention was implementing the Behavioral Activity Rating Scale in the ED electronic medical record. Data were collected through retrospective chart review and nurse survey. From September through December of both 2017 and 2018, data were collected on restraint use. The 4-month 2018 data collection period included measures of Behavioral Activity Rating Scale documentation and the System Usability Scale survey for nurses to measure ease of usability of the Behavioral Activity Rating Scale.

RESULTS

The Behavioral Activity Rating Scale was documented frequently (n = 4 867 documentations) by emergency nurses to assess patients with behavioral health and medical complaints (n = 780). Nurses identified 18 episodes of violent behavior in behavioral health patients on the Behavioral Activity Rating Scale (2.31%) and applied restraints 18 times. The most common chief complaints for patients who were identified as violent was suicidal ideation (n = 6; 33.33%). In 2017, there were 20 episodes of restraint use during the same time period, a nonsignificant difference (χ² = 0.72; P = 0.40). However, only 2 patients were kept in restraints longer than 1 day in 2018 compared with 8 in 2017. Emergency nurses found the Behavioral Activity Rating Scale to be usable in the structured usability assessment (μ = 83.46; SD = 11.73).

DISCUSSION

The Behavioral Activity Rating Scale is a usable tool for emergency nurses to assess for patient agitation. With the incorporation of agitation management interventions, the ED team can potentially manage agitation before violence occurs. Further studies are needed on the use of agitation or aggression assessment tools for managing patient behavioral activity such as aggression in the emergency department.

Violence and aggression in psychiatric inpatient care in Sweden: a critical incident technique analysis of staff descriptions

BACKGROUND

Violence towards staff working in psychiatric inpatient care is a serious problem. The aim of the present study was to explore staff perspectives of serious violent incidents involving psychiatric inpatients through the following research questions: Which factors contributed to violent incidents, according to staff? How do staff describe their actions and experiences during and after violent incidents?

METHODS

We collected data via a questionnaire with open-ended questions, and captured 283 incidents reported by 181 staff members from 10 inpatient psychiatric wards in four different regions. We used the Critical Incident Technique to analyse the material. Our structural analysis started by structuring extracts from the critical incidents into descriptions, which were grouped into three chronological units of analyses: before the incident, during the incident and after the incident. Thereafter, we categorised all descriptions into subcategories, categories and main areas.

RESULTS

Staff members often attributed aggression and violence to internal patient factors rather than situational/relational or organisational factors. The descriptions of violent acts included verbal threats, serious assault and death threats. In addition to coercive measures and removal of patients from the ward, staff often dealt with these incidents using other active measures rather than passive defence or de-escalation. The main effects of violent incidents on staff were psychological and emotional. After violent incidents, staff had to continue caring for patients, and colleagues provided support. Support from managers was reported more rarely and staff expressed some dissatisfaction with the management.

CONCLUSIONS

As a primary prevention effort, it is important to raise awareness that external factors (organisational, situational and relational) are important causes of violence and may be easier to modify than internal patient factors. A secondary prevention approach could be to improve staff competence in the use of de-escalation techniques. An important tertiary prevention measure would be for management to follow up with staff regularly after violent incidents and to increase psychological support in such situations.

Newly qualified nurses' perceptions of working at mental health facilities: A qualitative study

WHAT IS ALREADY KNOWN ABOUT THE TOPIC?: Newly qualified nurses often feel overwhelmed by the challenges of the work environment and struggle to transition into healthcare work environments. Nurses require opportunities during the transition period to develop both competence and confidence in their ability to practise independently. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Newly qualified mental health nurses experience fear during their adaptation period, especially when they perceive mental healthcare users as dangerous and the working environment as risky, with little concern for their safety. Nurses new to the mental health environment learn from accepting responsibility, taking on challenges and making adjustments, in order to develop confidence as mental healthcare professionals. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nursing management should ensure a safe and supportive mental healthcare environment. The potential for and consequences of negative stereotyping of patients among mental health nurses should be acknowledged and addressed as it may hinder the smooth adaptation of newly qualified nurses. Although stressful experiences can help mental health nurses to develop confidence and skills to manage future demanding situations, newly qualified nurses need to be given appropriate support and debriefing to ensure challenging situations do not "go the wrong way" and decrease confidence levels. Abstract Introduction Much has been written about the experiences of newly qualified nurses in their first year of employment, yet not much has been heard from the perspectives of newly qualified nurses working in mental health facilities. Aim To explore and describe the adaptation process of newly qualified nurses working in public mental health facilities in South Africa. Method Following a qualitative descriptive design, 11 newly qualified nurses in their first 6-18 months of employment were purposively selected from three public mental health facilities in South Africa. Data collected through unstructured individual interviews were thematically analysed. Results Four themes emerged from the analysis: fear related to the mental healthcare environment; self-doubt upon meeting the expectations of the inter-professional team; ways to adjust to the challenges; and confidence as mental healthcare professionals. Discussion During the adaptation process newly qualified nurses working in mental health facilities need support to overcome their initial fears and develop self-confidence in both managerial and therapeutic realms. Implications for practice Management of mental healthcare facilities needs to be cognisant of the importance of creating a supportive and safe environment that discourages negative stereotyping of patients and fosters newly qualified nurses' adaptation.

Consumer recommendations for enhancing the Safewards model and interventions

This paper critiques the Safewards model through the lens of lived experiences of psychiatric hospitalization, diagnosis of mental illness, and distress. Special focus is given to the model's tested 10 interventions and to five lesser known interventions, identifying the impact they can have on hospitalized consumers. We highlight the role and prevalence of trauma, as well as the need to prevent harm in hospital settings. We draw upon notions of hospital as a sanctuary for people and the importance of providing a safe ward. 'Sanctuary harm' and 'Sanctuary trauma' are thus defined, with emphasis placed on the Safewards interventions as means by which sanctuary can be achieved. Finally, the consumer-perspective authors propose expansions to the model, critiquing the defining literature and moving towards a consumer experience of safety that is beyond the model's original intention: to reduce seclusion and restraint practices. Throughout the paper, the term 'consumer' is used in this context to mean people who have experienced or are experiencing psychiatric inpatient care.

Psychiatric Institutions and the Physical Environment: Combining Medical Architecture Methodologies and Architectural Morphology to Increase Our Understanding

The pluralism that characterized the development of psychiatric services around the world created a variety of policies, care models and building types, and fostered experimental approaches. Increased complexities of care, institutional remnants, stigma, and the limited diagnostic and interventional accuracy of psychiatric treatments resulted in institutional behaviors surviving, even in newly built facilities. This was raised by research on awarded psychiatric buildings. The locus of the research comprised two acute psychiatric wards in London. Each was evaluated using the SCP model, a tool specifically developed for the evaluation of mental health facilities, identifying the relation between policy, care regime, and patient-focused environment. Data were derived from plans, visits, and staff and patient interviews. Findings were juxtaposed to those of an earlier study using the same methodology. Also, a syntactic analysis was conducted, to identify the social logic of ward layouts. There were potential connections between regimes, spatial configuration, and the social fabric. Methodologies of architectural morphologies indicated areas that would attract people because of the layout rather than function. However, insights into medical architecture outlined institutional undercurrents and provided alternative interpretation to spatial analysis. Comprehending the social fabric of psychiatric facilities could challenge the current surveillance-led model, as psychosocial rehabilitation uses could be encouraged at points of higher integration.

Joint BAP NAPICU evidence-based consensus guidelines for the clinical management of acute disturbance: De-escalation and rapid tranquillisation

The British Association for Psychopharmacology and the National Association of Psychiatric Intensive Care and Low Secure Units developed this joint evidence-based consensus guideline for the clinical management of acute disturbance. It includes recommendations for clinical practice and an algorithm to guide treatment by healthcare professionals with various options outlined according to their route of administration and category of evidence. Fundamental overarching principles are included and highlight the importance of treating the underlying disorder. There is a focus on three key interventions: de-escalation, pharmacological interventions pre-rapid tranquillisation and rapid tranquillisation (intramuscular and intravenous). Most of the evidence reviewed relates to emergency psychiatric care or acute psychiatric adult inpatient care, although we also sought evidence relevant to other common clinical settings including the general acute hospital and forensic psychiatry. We conclude that the variety of options available for the management of acute disturbance goes beyond the standard choices of lorazepam, haloperidol and promethazine and includes oral-inhaled loxapine, buccal midazolam, as well as a number of oral antipsychotics in addition to parenteral options of intramuscular aripiprazole, intramuscular droperidol and intramuscular olanzapine. Intravenous options, for settings where resuscitation equipment and trained staff are available to manage medical emergencies, are also included.

The experience of being a psychiatric nurse in South Africa: A qualitative systematic review

PURPOSE

The purpose of the study was to summarize the experiences of African psychiatric nurses in their workplace by examining the findings of existing qualitative studies.

METHODS

Eleven studies published in English, Portuguese, and Spanish, between 1998 and 2016, which explored psychiatric nurses' experiences in Africa, were included.

FINDINGS

After meta-aggregation, five key findings were identified: 1) organization and management, 2) perceptions of professional safety and insecurity, 3) relationship with the patient, 4) emotional experiences and 5) recommendations for improvement.

DISCUSSION

The findings in this study highlight the stressful nature of the work climate of the psychiatric nurse in South Africa. More focus on improving working conditions and providing support is necessary to increase the quality of care for psychiatric mental health patients and their nurse providers.

An Analysis of the Correlates of Aggression in a Social Learning Program for Severely and Persistently Mentally Ill Inpatients

PURPOSE

This study aimed to examine the relationship between behavioral variables and aggression among severely and chronically mentally ill inpatients in a Social Learning Program (SLP) at a state psychiatric facility.

METHODS

Using archival data over a 24-month period, a total of 23 severely and chronically mentally ill inpatients comprised the sample in this study. The predictor variables included length of current hospitalization; length of stay on SLP; basic activities of daily living (ADLs); instrumental ADLs; attendance in programming; participation in programming; and the number of minor, major, and intolerable infractions received. The criterion variable was number of aggressive episodes (e.g., hitting persons or objects).

RESULTS

Results of a standard multiple regression analysis indicated an overall model of two predictors (intolerable infractions and instrumental ADLs) that significantly predicted number of aggressive episodes. Findings suggested that SLP patients who have a tendency to be aggressive are able to adequately and concurrently complete daily hygiene needs and participate in scheduled treatment groups and activities.

DISCUSSION

Our findings provide valuable information regarding aggressive tendencies that can inform treatment planning. Specifically, our results suggested there are not necessarily obvious warning signs for aggression among severely and persistently mentally ill inpatients. Rather, other individualized patient factors may be at play in the expression of aggressive impulses, emphasizing the importance of adequate staff-to-patient ratios so that care planning and implementation can be appropriately individualized.

Patient perspectives on barriers and enablers to the use and effectiveness of de-escalation techniques for the management of violence and aggression in mental health settings

AIM

Investigate patient perspectives on barriers and enablers to the use and effectiveness of de-escalation techniques for aggression in mental health settings.

BACKGROUND

De-escalation techniques are the recommended first-line intervention for the management of aggression in mental health settings internationally, yet use of higher risk restrictive practices persists. This indicates de-escalation techniques are not used at optimum frequency and/or there are important factors limiting their use and effect.

DESIGN

Descriptive qualitative research using semi-structured interviews and Framework Analysis.

METHODS

Inpatient interviews (N = 26) exploring staff, patient and environmental factors influencing the use and effectiveness of staff de-escalation were conducted mid-2014. Three service user researchers led analysis.

RESULTS

Data were synthesized in three deductive themes relating to staff, patient and environmental influences on the use and effectiveness of de-escalation techniques. The dominant view was that restrictive practices, rather than de-escalation techniques, are used in response to escalating patient behaviour. Under-use of de-escalation techniques was attributed to: lack of staff reflection on culture and practice and a need to retain control/dominance over patients. Ward rules, patient factors and a lack of staff respect for patients diluted their effectiveness. Participants identified a systematic process of de-escalation, rule subversion, reduced social distance and staff authenticity as enablers of effective de-escalation.

CONCLUSION

This study investigated patient perspectives on staff, patient and environmental influences on the use and effectiveness of de-escalation techniques. Our framework of barriers and enablers provides indicators of organizational/behaviour change targets for interventions seeking to reduce violence and restrictive practices through enhanced de-escalation techniques.

Stress among employees in psychiatric nursing

Introduction: Evidence suggests that stressful situations are frequent in the field of psychiatry and that professionals working in this speciality are more prone to stress. Stressful situations may be compounded by ignoring the principles and strategies of therapeutic communication in all interactions with patients. The purpose of the research was to determine the presence of stress among the nursing team members. Methods: The research is based on a quantitative methodology; the data were collected using a semi-structured questionnaire. The sample consisted of 73 nurses working in a special social welfare institution (n = 37) and in a psychiatric hospital (n = 36). The survey was conducted in the first half of the year 2016. Descriptive statistics and chi-square test were used. Results: The list of stress factors most frequently reported by the participants include low pay (n = 40, 55 %), poor interpersonal relationships in the workplace (n = 23, 32 %), and the sense of insecurity due to unpredictable behaviour of patients (n = 32, 44 %). One fifth of the respondents are regularly subjected to patient physical violence and psychological abuse in the workplace (n = 14, 19 %) and a large majority (n = 53, 72.5 %) are frequently exposed to dangerous situations. The respondents are not fully aware of the crucial importance of therapeutic communication with the patients (n = 38, 52 %). Discussion and conclusion: It is impossible to completely avoid stressful situations in psychiatric settings. Psychiatric nurses should possess good communication skills and the ability to develop good interpersonal relationships.