The response of nursing staff to psychiatric inpatient misdemeanour

An Integrative Review on Psychiatric Intensive Care

Psychiatric intensive care units (PICUs) provide care and treatment when psychiatric symptoms and behaviors exceed general inpatient resources. This integrative review aimed to synthesize PICU research published over the past 5 years. A comprehensive search in MEDLINE, PsycINFO, PubMed and Scopus identified 47 recent articles on PICU care delivery, populations, environments, and models. Research continues describing patient demographics, and high rates of challenging behaviors, self-harm, and aggression continue being reported. Research on relatives was minimal. Patients describe restrictive practices incongruent with recovery philosophies, including controlling approaches and sensory deprivation. Some initiatives promote greater patient autonomy and responsibility in shaping recovery, yet full emancipatory integration remains limited within PICU environments. Multidisciplinary collaboration is needed to holistically advance patient-centered, equitable, and integrative PICU care. This review reveals the complex tensions between clinical risk management and emancipatory values in contemporary PICU settings. Ongoing reporting of controlling practices counters the recovery movement progressing in wider mental healthcare contexts. However, care innovations centered on patient empowerment and humane environments provide hope for continued evolution toward more liberation-focused PICU approaches that uphold both patient and provider perspectives.

Discrimination against offenders with mental disorder

BACKGROUND

Mentally disordered offenders may suffer discrimination on the basis of mental disorder, or on the basis of being offenders, or both.

AIMS

The aim of this paper is to outline a framework for examining discrimination affecting mentally disordered offenders. It is argued that there should be systematic comparisons between offenders with mental disorder and nonoffenders with mental disorder in order to identify and characterise specific failures to ensure equivalence of mental health care; and systematic comparisons between offenders with mental disorder and offenders without mental disorder in order to identify how mental disorder may constitute a barrier to forms of support and constructive intervention available to other offenders.

METHODS

A critical review was conducted of official documents presenting criminal justice and mental health policy for England and Wales, principally since 2012, together with reports of inspectorate and oversight bodies and relevant research studies.

FINDINGS

There is evidence that offenders with mental disorder may not be able to access mental health care equivalent to that for nonoffenders with mental disorder. There is also evidence that they may not be able to access interventions available to other offenders. Further disadvantage may arise in the criminal courts since, in England and Wales, if inpatient care is required, the powers of criminal courts to effect hospital admission under Part III of mental health legislation are weakened by the statutory requirement of information that places are available. This is discriminatory against offenders with mental disorder insofar as forms of court disposal for other offenders are not prevented by the capacity of criminal justice agencies.

CONCLUSIONS AND IMPLICATIONS

The review supports the need for systematic comparisons to identify forms of disadvantage and discrimination experienced by mentally disordered offenders in relation to both mental health and criminal justice policies services.

Moral mindfulness: The ethical concerns of healthcare professionals working in a psychiatric intensive care unit

Healthcare professionals working on inpatient wards face the externalizing or challenging behaviour of the patients who are admitted. Ethical values and principles in psychiatric nursing have been reported to be important when approaching patients during the most acute phase of deterioration in their mental health. Hence, the aim of this study was to discover and describe staff members' ethical and moral concerns about their work as healthcare professionals in a psychiatric intensive care unit. The study has a qualitative descriptive design and makes use of Framework Analysis. Registered nurses and psychiatric aides in a psychiatric intensive care unit in Sweden were observed during ethical reflection meetings. Four to six staff attended the 90-min meetings. The data comprise observations from six meetings, which provided 94 pages of text. The results demonstrate that the work was described as being both motivating and exhausting. The staff faced ethical concerns in their daily work, as patients often demonstrated challenging behaviours. Three themes were identified as follows: (i) concerns about the staff impacting on patients' experience of care, (ii) concerns about establishing a safe working environment, and (iii) concerns about becoming unprofessional due to expectations and a high workload. Ethical concerns included simultaneously taking into account both the patients' dignity and safety aspects, while also being exposed to high workloads. These elements of work are theorized as influencing complex psychiatric nursing. If we are to bring these influential factors to light in the workplace, advanced nursing practice must be grounded in moral mindfulness.

A growing evidence base for management guidelines

We review key recent research and guidance for staff working with acutely disturbed psychiatric patients. Assessment of aggressive patients and their situation should enable full risk assessment, which may ideally involve the use of advance directives. We discuss appropriate use of the Mental Health Act 1983 and consider benefits and adverse effects of rapid tranquillisation. We present a simple protocol for oral or intramuscular rapid tranquillisation. Staff using physical restraint should be properly trained and consider sensitively issues of the patient's diginity, gender and the most appropriate location for restraint to occur. Simple precautions can improve safety when working with potentially disturbed patients. Staff need support during and after the management of an aggressive incident.

Using Participatory Action Research to Develop a Working Model That Enhances Psychiatric Nurses' Professionalism: The Architecture of Stability

Ward rules in psychiatric care aim to promote safety for both patients and staff. Simultaneously, ward rules are associated with increased patient violence, leading to neither a safe work environment nor a safe caring environment. Although ward rules are routinely used, few studies have explicitly accounted for their impact. To describe the process of a team development project considering ward rule issues, and to develop a working model to empower staff in their daily in-patient psychiatric nursing practices. The design of this study is explorative and descriptive. Participatory action research methodology was applied to understand ward rules. Data consists of audio-recorded group discussions, observations and field notes, together creating a data set of 556 text pages. More than 100 specific ward rules were identified. In this process, the word rules was relinquished in favor of adopting the term principles, since rules are inconsistent with a caring ideology. A linguistic transition led to the development of a framework embracing the (1) Principle of Safety, (2) Principle of Structure and (3) Principle of Interplay. The principles were linked to normative guidelines and applied ethical theories: deontology, consequentialism and ethics of care. The work model reminded staff about the principles, empowered their professional decision-making, decreased collegial conflicts because of increased acceptance for individual decisions, and, in general, improved well-being at work. Furthermore, the work model also empowered staff to find support for their decisions based on principles that are grounded in the ethics of totality.

Re-framing the problem of workplace violence directed towards nurses in mental health services in the UK: a work in progress

BACKGROUND

Research consistently suggests nurses working in mental health settings are more likely to be assaulted than nurses in other settings.

AIMS

Belated recognition of the issue in terms of social policy (Elston et al. 2006) has been accompanied by an as yet unexamined contest between conflicting 'frames' of the problem, which this paper seeks to make transparent.

METHOD

Frame analysis.

RESULTS

Two distinct 'master' frames are discussed: the 'individualizing' and the 'co-creationist'.

CONCLUSIONS

The influence of these frames has influenced the nature of responses to the problem but the recent dominance of the individualizing frame is being challenged by the emergence, or perhaps re-emergence, of co-creationism.

An analysis of nurses' post-incident manual restraint reports

Manual restraint techniques are associated with the management of violence in psychiatric settings. Restraint effectiveness and acceptability are under scrutiny, yet the nature and frequency of who or what were involved in restraint episodes have not previously been fully described or understood. The aim of this study was to describe the nature and frequency of manual restraint-related events and their components. This study was carried out using content analyses of nurses' post-incident reports from a psychiatric unit situated within a general hospital, and from its associated medium-secure unit. Requests for restraint occurred at the rate of about once per day, and the majority related to patients' ill-directed frustration, resistance to containment and their desire to leave the ward. Only half of responses to conflicts resulted in restraint implementation. The majority of restraint activities occurred during the afternoon and night. Male patients and detained patients were more frequent participants in restraint interventions. To a lesser extent, police, ambulance, fire services, hospital security, visitors and ex-patients were also involved in restraint episodes. Injuries were rare. In conclusion, training in restraint skills, clinical audit of adverse incidents, and research into psychiatric aggression all need to take into account the association of restraint with the enforcement of detention and treatment of acutely ill patients. The coupling of restraint with medication requires examination of its safety and efficacy. Interagency training may enable the essential services involved to coordinate restraint activities more effectively.

Patients' feelings about ward nursing regimes and involvement in rule construction

This study compared two acute psychiatric ward nursing regimes, focusing on ward rules as a means of investigating the relationship between the flexibility/inflexibility of the regimes and patient outcomes. Previous studies identified an association between ward rules and patient aggression. A link between absconding and nurses' attitudes towards rule enforcement has also been explored. However, an in-depth exploration of ward rules from the perspective of nurses and patients had not been undertaken previously. The study aimed to discover the content of rules within acute psychiatric wards; to explore patients' responses to the rules; to evaluate the impact of rules and rule enforcement on nurse-patient relationships and on ward events; and to investigate the relationship between ward rules, ward atmosphere and ward design. The relevance of sociological theory emerged from the data analysis. During this process, the results were moved up to another conceptual level to represent the meaning of lived experience at the level of theory. For example, nurses' descriptions of their feelings in relation to rule enforcement were merged as role ambivalence. This concept was supported by examples from the transcripts. Other possible explanations for the data and the connections between them were checked by returning to each text unit in the cluster and ensuring that it fitted with the emergent theory. The design centred on a comparative interview study of 30 patients and 30 nurses within two acute psychiatric wards in different hospitals. Non-participant observations provided a context for the interview data. Measures of the Ward Atmosphere Scale, the Hospital-Hostel Practices Profile, ward incidents and levels of as required (PRN) medication were obtained. The analysis of the quantitative data was assisted by spss, and the qualitative analysis by QSR *NUDIST. Thematic and interpretative phenomenological methods were used in the analysis of the qualitative data. A series of 11 interrelated concepts emerged from an analysis of the data, and a synthesis of the main themes. This paper focuses on the results and recommendations that emerged from the quantitative and qualitative patient data. A further paper will focus on nurses' perceptions of the same topics.

Staff gender ratio and aggression in a forensic psychiatric hospital

Gender balance in acute psychiatric inpatient units remains a contentious issue. In terms of maintaining staff and patient safety, 'balance' is often considered by ensuring there are 'sufficient' male nurses present on each shift. In an ongoing programme of research into aggression, the authors investigated reported incidents of patient aggression and examined the gender ratio on each shift over a 6-month period. Contrary to the popular notion that a particular gender ratio might have some relationship with the likelihood of aggressive incidents, there was no statistically significant difference in the proportion of male staff working on the shifts when there was an aggressive incident compared with the shifts when there was no aggressive incident. Further, when an incident did occur, the severity of the incident bore no relationship with the proportion of male staff working on the shift. Nor did the gender of the shift leader have an impact on the decision to seclude the patient or the likelihood of completing an incident form following an aggressive incident. Staff confidence in managing aggression may be influenced by the presence of male staff. Further, aspects of prevention and management may be influenced by staff gender. However, results suggest there is no evidence that the frequency or severity of aggression is influenced by staff gender ratio.

A study of psychiatric nurses' beliefs and attitudes about work safety and assaults in Turkey

In Turkey, the cultural structure effects the gender roles in the society, and women are subject to violence in an intense manner both inside the family and in their workplaces. In nursing, which is still defined as a woman's job in our country, it is possible to encounter many aggressive and threatening behaviours. Knowing no geographical borders, aggression leads to dissatisfaction and alienation with the profession for the nurses working at the psychiatric institutions in Turkey, thus aggression is a significant health risk in physical, psychological and social dimensions. The research was carried out with 162 randomly selected nurses working in the psychiatric institutions in Istanbul using the Attitudes Toward Patient Physical Assault Questionnaire. It has been determined that nurses' rate of exposure to verbal/physical assault by the patients and their relatives is high and that they experience an intense uncertainty and conflict, especially in legal issues, and that the duration of working in the psychiatry clinics effects attitudes toward the assaults. It is concluded that the nurses working at the psychiatry clinics in Turkey are under risk in regards to safety and they need protection and support, both in emotional and in legal terms.

Coercive manoeuvres in a psychiatric intensive care unit

Coercive manoeuvres in a psychiatric intensive care unit The practice of physical restraint techniques in the management of disturbed behaviour is a significant part of the role of mental health nurses, particularly in Psychiatric Intensive Care Units (PICUs). Debate about what constitutes good practice is intense, and the subject of recently issued guidelines by National Institute for Mental Health in England. However, the contribution of other forms of conflict management techniques has tended to be ignored. The purpose of this study was to identify, describe and categorize coercive manoeuvres used by nurses, and to examine the circumstances and appropriateness of their use. Non-participant observation of verbal and non-verbal interaction between patients and nurses during conflict situations was undertaken on one PICU. The critical incidents observed were identified, categorized and systematically recorded. Nurses used a variety of low level physical and interactional manoeuvres in order to manage patients' disturbed and resistive behaviour. These manoeuvres were seldom recorded, discussed or reviewed, although they were frequently used to manage critical conflict situations. These manoeuvres have neither been previously described nor evaluated. They may, in some cases, be useful substitutes for actual restraint, alternatively they may, in some cases, be judged undesirable. It is not known how widespread these practices are in acute psychiatry.

Patient and nurse accounts of violent incidents in a medium secure unit

Most studies examining violence in a forensic setting have adopted a statistical approach to associate relevant predictors and the likelihood of violence. Views of patients and nurses have been a relatively neglected research area. This study explored patients' and nurses' accounts of violent incidents, considering similarities and differences in their narratives. Permission was obtained from the local National Health Service Research Ethics Board and the Research Ethics Committee of University of East London. Anonymized transcripts were produced from semi-structured interviews conducted in a Medium Secure Unit with four nurses and four patients, who consented to talk at length with the first author about violent events they had witnessed on the Unit. Grounded theory analysis of the data generated a core category, 'control', and five constituent themes: the construction of identity of the perpetrator of violence; nurses' dual role of caring and controlling; aspects of parentalism involved in control; following set policies and procedures; and segregation from mainstream society. Because of widespread social interest and media coverage in the topic, discursive examination was made of aspects of social context arising within the data. This study was small scale and exploratory, and further confirmatory research is needed. Nevertheless, clear contrasts between the nurse and patient accounts indicated tentative suggestions for training (including user involvement) and intervention in managing violent behaviour.

Limit-setting and decision-making in the management of aggression

BACKGROUND

Several published research studies have suggested that inpatient aggression against nursing staff may be directly precipitated by common nurse-patient interactions. This study sought to examine the structure of nurses' judgements in situations of conflict.

METHOD

Seventy practising United Kingdom psychiatric nurses were presented with a number of conflict scenarios and were asked to rate a range of intervention options for each scenario according to how appropriate they perceived those interventions to be. Their responses were analysed using multidimensional scaling techniques.

RESULTS

The results suggest that issues associated with limit setting and autonomy were perceived as most important by the nurses and that these issues are most likely to lead to disagreements in judgement between nurses of different status. Nurses of higher grades (levels) showed a significantly greater preference for respectful and autonomy-confirming interventions than their more junior nurses. These results have training and policy implications and further research should examine the effects of such nursing judgements on patient care.

HOVIS -- The Hertfordshire/Oxfordshire Violent Incident Study

Violence in psychiatric inpatient units is a major and growing problem. Research interest has primarily focussed on patient characteristics. The role of staff factors and the antecedents of violent incidents has been neglected, despite the fact that staff factors and behaviour may be more readily amenable to change than patient characteristics. The HOVIS study sought to obtain the views of a sample of mental health nurses in current clinical practice about staff-related factors, which they perceive to contribute to, or protect against, the occurrence of violent incidents. A total of 108 nurses working in psychiatric acute admission, intensive care and low secure units, in two NHS Trusts were interviewed using a specially designed semistructured interview schedule. These nurses identified a variety of behaviours, clinical skills, personal characteristics and interpersonal skills that they believe impact on the occurrence of violent incidents. These findings are discussed in relation to their possible training and managerial implications.

Responding to inpatient violence at a psychiatric hospital of special security: a pilot project

Within secure psychiatric hospitals, staff have to manage many difficult and challenging situations. Crichton (1997) suggested that when staff perceive a greater degree of responsibility on patients for their actions there is a particularly morally censorious response. The aim of this pilot study was to discover if this association, discovered using a hypothetical scenario, was also present in how nursing staff respond to real violent patient behaviour. Over a five week period all episodes of inter-personal violence in a hospital with special security were identified and those involved interviewed. Thirty-one episodes of inter-personal violence were identified. A disproportionate number were caused by female patients and patients detained under civil sections of mental health legislation. A personality disorder diagnosis and the staff belief that mental disorder did not reduce the individual patient's blame for the incident were associated with the response of a restrictive sanction (both cases p < 0.01).