Aggressive behaviour on acute psychiatric wards: prevalence, severity and management

Assessment of the Frequency, Causes, Degree and Consequences of Violence against Health Workers in Psychiatric Institutions

(1) Background: The prevalence of workplace violence within the health sector varies between 50 and 88%. Depending on the health care environment, the percentages mentioned can be much higher. (2) The aim of this study was to determine the prevalence, characteristics, factors, and consequences of violence against healthcare workers (physicians, nurses, and technicians) in psychiatric institutions in the Republic of Serbia. Additionally, this study should validate the Serbian version of the aggression questionnaire, which could be a significant tool in recognizing and assessing any type of violence against health care workers in psychiatric institutions. (3) Methods: This study was designed as an observational questionnaire study that included 191 health workers (physicians, medical technicians, workers in kitchens or maintenance, and others) from three psychiatric institutions. As an instrument, this study validated and used the Serbian version of the aggression standardized questionnaire. We observed the primary and secondary outcomes of potential violence in psychiatric institutions against healthcare workers using different parameters. (4) Results: The internal consistency of each item as well as the instrument was very good (the mean Cronbach alfa = 0.91). A total of 104 of the participants never experienced physical violence, while more than five times that had 20 health workers (10.5%). We observed the statistical significance of gender, age, working status (permanent/limited) and professional status (physician/medical technician/worker etc.) on physical attack incidence. (5) Conclusions: The incidence of violence against healthcare workers is very high, especially in terms of physical assault and threats in the workplace. The majority of the victims were women who work as medical technicians, attacked by male patients with unknown motivation. A number of changes in the structure and organizational culture of the hospital are required. All hospital employees, employers, patients, and their families share responsibility for the creation of a safe workplace.

Incidence, Severity and Characteristics of Patients' Aggression in Acute Psychiatric Wards: Data from a Slovenian National Survey

Aim

To evaluate the incidence, severity and characteristics of aggressive behaviour in patients hospitalized in acute psychiatric wards, as well as the association between patient characteristics and the incidence of recurrent aggressive behaviour.

Methods

A multicentre prospective study included all twelve acute wards in Slovenian psychiatric hospitals with a total capacity of 232 beds. Over five consecutive months, data on the number of treatment episodes involving aggressive behaviour and the number of aggressive incidents, their severity and characteristics were obtained using the Staff Observation Aggression Scale-Revised (SOAS-R). Patient- and event-based incident rates of verbal and physical aggression were calculated. The association between patient characteristics and recurrent aggressive behaviour was analysed. Patient characteristics data were extracted from hospital databases.

Results

3,190 treatment episodes were included during a 5-month period. Aggressive behaviour was observed in 13.4% of treatment episodes, and 922 aggressive incidents were recorded, which resulted in 3.98 incidents per 100 occupied bed days and 9.48 incidents per bed per year. 74.1% of incidents were severe, and more than half of incidents included physical aggression. 75.5% of incidents were directed against medical staff. 5.9% of treatment episodes were involved in multiple aggressive incidents. Compared to patients with single incidents, patients with recurrent aggression had a less frequent main diagnosis of substance use disorders and a longer duration of hospitalization.

Conclusion

Monitoring the frequency and characteristics of aggressive behaviour allows comparisons with other studies and, more importantly, it is necessary for planning and assessing the effectiveness of preventative aggression management strategies.

The experiences of nurses following seclusion or restraint use and immediate staff debriefing in inpatient mental health settings

AIM

The aim of this study is to explore nurses' experiences of seclusion or restraint use and their participation in immediate staff debriefing in inpatient mental health settings.

DESIGN

This research was conducted using a descriptive exploratory design and data were gathered through in-depth individual interviews.

METHODS

The experiences of nurses following seclusion or restraint use and their participation in immediate staff debriefing were explored via teleconference, using a semi-structured interview guide. Reflexive thematic analysis was used to identify prevalent themes from the data.

RESULTS

Interviews (n=10) were conducted with nurses from inpatient mental health wards in July 2020. Five themes emerged through the data analysis: (i) ensuring personal safety; (ii) grappling between the use of least-restrictive interventions and seclusion or restraint use; (iii) navigating ethical issues and personal reactions; (iv) seeking validation from colleagues and (v) attending staff debriefing based on previous experience. The themes were also analysed using Lazarus and Folkman's Transactional Model of Stress and Coping.

CONCLUSION

Staff debriefing is a vital resource for nurses to provide and/or receive emotion- and problem-focused coping strategies. Mental health institutions should strive to establish supportive working environments and develop interventions based on the unique needs of nurses and the stressors they experience following seclusion or restraint use.

PATIENT OR PUBLIC CONTRIBUTION

Nurses in both frontline and leadership roles were involved in the development and pilot test of the interview guide. The nurses who participated in the study were asked if they can be recontacted if clarification is needed during interview transcription or data analysis.

Consistency of Violence: Implications for Effective Inpatient Psychiatric Care

Instances of violence and aggression in acute psychiatric settings are common and highly distressing for service users and staff. They also incur financial costs. This study aimed to identify the proportion of service users at risk of consistent violence/aggression enactment. It also aimed to analyse associated service use to explore the potential need for specialised, targeted approaches. Five years' worth of data were extracted from 2016 to 2020 on inpatient stays across South London and Maudsley NHS Foundation Trust (SLaM) acute adult wards and Psychiatric Intensive Care Units (PICUs). Service users were divided into cohorts based on relative number of violent/agressive incidents enacted. Differences in frequency of acute service use during the period 1st January-31st December 2020 were analysed. In total, 2524 service users had at least one inpatient stay during 2020. 679 were recorded as having enacted at least one incident of violence or aggression. Just 4% of all service users accounted for 50% of all violence/aggression enactment. Results further showed strong evidence of group differences between violence cohorts in the following domains: internal transfers, occupied bed days, admissions and Place of Safety (PoS) referrals. There was weaker evidence for group differences in referrals to Home Treatment teams (HTTs) and Psychiatric Liaison Teams. A small proportion of service users disproportionately account for the majority of violent and aggressive incidents and higher levels of violence and aggression are associated with more acute service use. The provision of targeted, personalised interventions for this cohort may reduce the enactment of violence and aggression, leading to improved quality life and a reduction in financial expenditure.

Offenders and non-offenders with schizophrenia spectrum disorders: Do they really differ in known risk factors for aggression?

Introduction

Individuals with schizophrenia spectrum disorders (SSD) have an elevated risk for aggressive behavior, and several factors contributing to this risk have been identified, e. g. comorbid substance use disorders. From this knowledge, it could be inferred that offender patients show a higher expression of said risk factors than non-offender patients. Yet, there is a lack of comparative studies between those two groups, and findings gathered from one of the two are not directly applicable to the other due to numerous structural differences. The aim of this study therefore was to identify key differences in offender patients and non-offender patients regarding aggressive behavior through application of supervised machine learning, and to quantify the performance of the model.

Methods

For this purpose, we applied seven different (ML) algorithms on a dataset comprising 370 offender patients and a comparison group of 370 non-offender patients, both with a schizophrenia spectrum disorder.

Results

With a balanced accuracy of 79.9%, an AUC of 0.87, a sensitivity of 77.3% and a specificity of 82.5%, gradient boosting emerged as best performing model and was able to correctly identify offender patients in over 4/5 the cases. Out of 69 possible predictor variables, the following emerged as the ones with the most indicative power in distinguishing between the two groups: olanzapine equivalent dose at the time of discharge from the referenced hospitalization, failures during temporary leave, being born outside of Switzerland, lack of compulsory school graduation, out- and inpatient treatment(s) prior to the referenced hospitalization, physical or neurological illness as well as medication compliance.

Discussion

Interestingly, both factors related to psychopathology and to the frequency and expression of aggression itself did not yield a high indicative power in the interplay of variables, thus suggesting that while they individually contribute to aggression as a negative outcome, they are compensable through certain interventions. The findings contribute to our understanding of differences between offenders and non-offenders with SSD, showing that previously described risk factors of aggression may be counteracted through sufficient treatment and integration in the mental health care system.

Patients' and staff members' experiences of restrictive practices in acute mental health in-patient settings: systematic review and thematic synthesis

BACKGROUND

Recent guidance has called for the reduction of restrictive practice use owing to growing concerns over the harmful physical and psychological effects for both patients and staff. Despite concerns and efforts, these measures continue to be used regularly to manage challenging behaviour in psychiatric in-patient settings.

AIMS

To undertake a systematic review of patients' and staff members' experiences of restrictive practices in acute psychiatric in-patient settings.

METHOD

A systematic review and thematic synthesis was conducted using data from 21 qualitative papers identified from a systematic search across three electronic databases (PsycInfo, Embase and MEDLINE) and citation searching. The protocol for the review was pre-registered on PROSPERO (CRD42020176859). The quality of included papers was examined using the Critical Appraisal Skills Programme (CASP).

RESULTS

Four overarching themes emerged from the experiences of patients: the psychological effects, staff communication, loss of human rights and making changes. Likewise, the analysis of staff data produced four themes: the need for restrictive practices, the psychological impact, decision-making and making changes. Patient and staff experiences of restrictive practices were overwhelmingly negative, and their use carried harmful physical and psychological consequences. Lack of support following restraint events was a problem for both groups.

CONCLUSIONS

Future programmes seeking to improve or reduce restrictive practices should consider the provision of staff training covering behaviour management and de-escalation techniques, offering psychological support to both patients and staff, the importance of effective staff-patient communication and the availability of alternatives.

The Ontario Forensic Mental Health System: A Population-based Review

OBJECTIVE

The purpose of this study was to increase the understanding of the Canadian forensic psychiatry system by providing a population-based overview of the Ontario forensic mental health system.

METHODS

Data were collected on 1,240 accused adults who were subject to the jurisdiction of the Ontario Review Board (ORB) between 2014 and 2015. Archival data were retrieved from annual ORB hearing hospital reports for accused supervised by all nine adult forensic psychiatry facilities across Ontario.

RESULTS

The sample included not criminally responsible (NCR; 91.6%) and unfit to stand trial (UST; 8.4%) accused. The majority of the sample was male (85.7%), single (70.1%), unemployed (63.6%), with a high school education (48.8%). Most were on a detention order (78.5%) and almost half were living in the community at the time of the report (48.8%). The majority had prior contact with psychiatric services (83.1%) and/or the criminal justice system (70.6%) before entering the forensic system. A history of elopement (31.5%) and inpatient aggression was high (60.6%). Most had a psychotic spectrum disorder (81.6%) and over half had a substance use disorder (57.2%) in the reporting year. A range of index offences was observed (69.9% violent, 20.3% general, 9.8% sexual), and the majority of the sample (61.0%) had an index offence that resulted in no injury or a minor injury to the victim.

CONCLUSION

The Canadian forensic psychiatry system is comprised of a unique subset of justice-involved individuals. This study provides a detailed examination of accused who are subject to the jurisdiction of the ORB and provides key insight into risk factors associated with offending behaviour in this population. The results of this study will provide a framework for future studies examining the association between mental disorder and violence and the treatment trajectories for those in the forensic psychiatry system.

Instruments for Measuring Violence on Acute Inpatient Psychiatric Units: Review and Recommendations

OBJECTIVE

Violence by patients against inpatient psychiatric unit staff is common, causing considerable suffering. Despite the Joint Commission's 2018 requirement for behavioral health organizations to use standardized instruments, no identified gold standard measures of violence and aggression exist. Therefore, accurate data are lacking on the frequency of patient-to-staff violence to guide development of safer institutional clinical policies or to assess the impact of targeted interventions to reduce violence. To inform recommendations for developing standardized scales, the authors reviewed the scoring instruments most commonly used to measure violence in recent studies.

METHODS

A comprehensive literature search for violence measurement instruments in articles published in English from June 2008 to June 2018 was performed. Review criteria included use of instruments measuring patient-to-staff violence or aggression in acute, nonforensic, nongeriatric populations. Exclusion criteria included child or adolescent populations, staff-to-staff violence, and staff- or visitor-to-patient violence.

RESULTS

Overall, 74 studies were identified, of which 74% used structured instruments to measure aggression and violence on inpatient psychiatric units during the past 10 years. The instruments were primarily variants of the Observed Aggression Scale (OAS); 26% of the studies used unstructured clinical notes and researcher questionnaires. Major obstacles to implementing measurement instruments included time and workflow constraints and difficulties with use.

CONCLUSIONS

In the past 10 years, OAS variants with evidence of validity and reliability that define aggression and violence have been consistently used. The authors propose that adapting the Modified OAS to collect real-time clinical data could help overcome barriers to implementing standardized instruments to quantify violence against psychiatric staff.

Workplace Violence, Workforce Stability, and Well-being in China's Psychiatric Hospitals

INTRODUCTION

Workplace violence against psychiatric professionals is a growing problem, yet nationally representative data in China are lacking. This study examines workplace violence against psychiatrists and psychiatric nurses in China as well as its association with workforce stability and well-being .

METHODS

Data came from a 2019 national survey of 14,264 participants (including 4,520 psychiatrists and 9,744 nurses) from 41 psychiatric hospitals across China. The occurrence of physical and verbal assaults among psychiatrists and psychiatric nurses was reported. Logistic regression models were constructed to examine the participants' characteristics associated with encountering workplace violence and the association of encountering violence with self-reported quality of life, health status, turnover intention, and career satisfaction. Analyses were performed during 2020.

RESULTS

In 2019, among 14,264 psychiatrists and psychiatric nurses in China, 81% reported encountering workplace violence during the past year. Psychiatrists were 0.68 (95% CI=0.55, 0.83) times less likely to report an encounter of violence than nurses. Male and younger nurses were 2.20 (95% CI=1.72, 2.81) and 1.21 (95% CI=1.01, 1.45) times more likely to report violence. Psychiatrists who had a higher educational degree or a higher professional rank were more vulnerable to violence. Encountering violence was significantly associated with poor quality of life, less satisfaction with health status, greater intention to leave the current job, and career dissatisfaction.

CONCLUSIONS

Workplace violence against psychiatrists and psychiatric nurses are common in China, indicating that China's psychiatric professionals are facing a significant threat to occupational safety. To maintain psychiatric workforce stability, actions are needed to reduce the prevalence of workplace violence at the system, institutional, and individual levels.

Prevalence and correlates of aggressive behavior in psychiatric inpatient populations

Aggressive behavior in patients with psychiatric disorders is attracting increasing research interest. One reason for this is that psychiatric patients are generally considered more likely to be aggressive, which raises a related question of whether diagnoses of psychiatric disorders predict the prevalence of aggressive behavior. Predicting aggression in psychiatric wards is crucial, because aggressive behavior not only endangers the safety of both patients and staff, but it also extends the hospitalization times. Predictions of aggressive behavior also need careful attention to ensure effective treatment planning. This literature review explores the relationship between aggressive behavior and psychiatric disorders and syndromes (dementia, psychoactive substance use, acute psychotic disorder, schizophrenia, bipolar affective disorder, major depressive disorder, obsessive-compulsive disorder, personality disorders and intellectual disability). The prevalence of aggressive behavior and its underlying risk factors, such as sex, age, comorbid psychiatric disorders, socioeconomic status, and history of aggressive behavior are discussed as these are the components that mostly contribute to the increased risk of aggressive behavior. Measurement tools commonly used to predict and detect aggressive behavior and to differentiate between different forms of aggressive behavior in both research and clinical practice are also reviewed. Successful aggression prevention programs can be developed based on the current findings of the correlates of aggressive behavior in psychiatric patients.

An Evaluation of the Implementation of a "No Force First" Informed Organisational Guide to Reduce Physical Restraint in Mental Health and Learning Disability Inpatient Settings in the UK

BACKGROUND

The use of physical restraint on vulnerable people with learning disabilities and mental health problems is one of the most controversial and criticised forms of restrictive practice. This paper reports on the implementation of an organisational approach called "No Force First" within a large mental health organisation in England, UK. The aim was to investigate changes in violence/aggression, harm, and physical restraint following implementation.

METHODS

The study used a pretest-posttest quasi-experimental design. Recorded incidents of violence/aggression from 44 inpatient mental health and learning disabilities (including forensic) wards were included (n = 13,599). Two study groups were created for comparison: the "intervention" group comprising all incidents on these wards during the 24 months post-implementation (2018-2019) (n = 6,551) and the "control" group comprising all incidents in the 24 months preceding implementation (2015-2016) (n = 7,048). Incidents recorded during implementation (i.e., 2017) were excluded (n = 3,705). Incidence rate ratios (IRR) were calculated with 95% confidence intervals (95% CI). Multivariate regression models using generalised estimating equations were performed to estimate unadjusted and adjusted prevalence ratios (aPR) of physical restraint and harm, using type of wards, incident, and violence/aggression as key covariates.

RESULTS

A significant 17% reduction in incidence of physical restraint was observed [IRR = 0.83, 95% CI 0.77-0.88, p < 0.0001]. Significant reductions in rates of harm sustained and aggression/violence were also observed, but not concerning the use of medication during restraint. The prevalence of physical restraint was significantly higher in inpatients on forensic learning disability wards than those on forensic mental health wards both pre- (aPR = 4.26, 95% CI 2.91-6.23) and post-intervention (aPR = 9.09, 95% CI 5.09-16.23), when controlling for type of incident and type of violence/aggression. Physical assault was a significantly more prevalent risk factor of restraint use than other forms of violence/aggression, especially that directed to staff (not to other patients).

CONCLUSIONS

This is a key study reporting the positive impact that organisational models and guides such as "No Force First" can have on equipping staff to focus more on primary and secondary prevention as opposed to tertiary coercive practices such as restraint in mental health and learning disabilities settings.

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.

Seclusion Reduction on an Adult Inpatient Psychiatric Unit: A Quality Improvement Project

Seclusion practices have traditionally been used in psychiatry to maintain patient and staff safety. Despite negative emotional consequences for all involved parties and the movement toward patient-centered care, these practices continue in in-patient psychiatric units across the United States. The purpose of the current quality improvement project was to decrease the rate of seclusion events on an adult inpatient psychiatric unit through the implementation of a standard debriefing process based on the National Association of State Mental Health Program Directors' Six Core Strategies for Reducing Seclusion and Restraint Use. In 2020, the seclusion rates at the project site were above state and national benchmarks. Post-intervention, the seclusion hours per 1,000 patient care hours increased by 16% (0.38 to 0.44); however, the mean duration of each seclusion episode decreased by 10% (158 minutes to 142 minutes). Intervention compliance was low, including interprofessional participation. These findings demonstrate the need to address seclusion practices with an evidence-based solution, such as debriefing, coupled with adequate support from interprofessional leadership. [Journal of Psychosocial Nursing and Mental Health Services, xx(xx), xx-xx.].

The incidence and economic impact of aggression in closed long-stay psychiatric wards

OBJECTIVE

Aggressive behaviour is highly prevalent in long-term psychiatric inpatient care. We aimed to estimate the overall incidence of aggression, the time staff took to handle aggression incidents, and the weighted average financial costs thereof.

METHODS

A random sampling procedure was conducted at long-term psychiatric inpatient care facilities. Nurses were asked to recall all incidents (i.e., verbal, physical towards objects, self, or others) of their shift. For the time spent on each type of incident, staff were monitored in real-time. Estimated costs were calculated by the time spent multiplied by hourly wages in addition to material-related costs.

RESULTS

Incidence rates were 90 incidents per patient year. The average time spent per incident was 125 min but differed for each type of incident. Almost 80% of this time was consumed by nursing staff. The average cost per aggression incident was €78; extrapolated per patient year, the total costs were approximately €7000.

CONCLUSIONS

The current study found a high rate of aggression incidents in closed long-stay psychiatric wards. Reports of aggression on these types of wards are scarce. Nevertheless, aggression seems to have a severe impact on invested time and related costs, which suggests a need for aggression-prevention and de-escalating programs.Key pointsAggression incidents are highly prevalent and are accompanied by high costs.The effect of aggression incidents on the workload for staff members is high, especially for nursing staff.Studies across countries on the incidence and the costs of aggression among psychiatric inpatients are needed to help model the effects of (new) strategies for aggression reduction.

Aggression on the psychiatric ward: Prevalence and risk factors. A systematic review of the literature

INTRODUCTION

On psychiatric wards, aggressive behaviour displayed by patients is common and problematic. Understanding factors associated with the development of aggression offers possibilities for prevention and targeted interventions. This review discusses factors that contribute to the development of aggression on psychiatric wards.

METHOD

In Pubmed and Embase, a search was performed aimed at: prevalence data, ward characteristics, patient and staff factors that are associated with aggressive behaviour and from this search 146 studies were included.

RESULTS

The prevalence of aggressive behaviour on psychiatric wards varied (8-76%). Explanatory factors of aggressive behaviour were subdivided into patient, staff and ward factors. Patient risk factors were diagnosis of psychotic disorder or bipolar disorder, substance abuse, a history of aggression, younger age. Staff risk factors included male gender, unqualified or temporary staff, job strain, dissatisfaction with the job or management, burn-out and quality of the interaction between patients and staff. Staff protective factors were a good functioning team, good leadership and being involved in treatment decisions. Significant ward risk factors were a higher bed occupancy, busy places on the ward, walking rounds, an unsafe environment, a restrictive environment, lack of structure in the day, smoking and lack of privacy.

CONCLUSION

Despite a lack of prospective quantitative data, results did show that aggression arises from a combination of patient factors, staff factors and ward factors. Patient factors were studied most often, however, besides treatment, offering the least possibilities in prevention of aggression development. Future studies should focus more on the earlier stages of aggression such as agitation and on factors that are better suited for preventing aggression such as ward and staff factors. Management and clinicians could adapt staffing and ward in line with these results.

The Model for Understanding Inpatient Aggression: A Version for Mental Health Nurses Working in Prisons

Preventing and managing aggression remains an important and challenging task for mental health nurses. Despite the concern, there is a dearth of frameworks to assist practice and inform assessment and intervention related to aggression, for forensic mental health nurses working in prisons. This paper presents a model for understanding aggression within prison mental health units. The model elucidates various personal and situational determinants of aggression. It offers a systematic framework for mental health nurses to investigate and understand aggression, to ultimately assist nurses to provide care in an informed and effective manner, and for services to consider structural factors that contribute to the risk of aggression.

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.

The omnipresence of risk and associated harms in secure and forensic mental health services in England and Wales

Current legislation and policy frameworks regulating the detention and treatment of mentally disordered offenders in England and Wales are predicated on the assumption that a minority of patients have enduring violent tendencies and pose a serious long-term risk to the safety of others. This paper seeks to consider the manner in which notions of risk and the imperative to contain and minimise the potential for harm, present and impact patients in secure and forensic mental health settings. Within this, we consider how mental health stigma and Beck's concept of the Risk Society can affect the thoughts and actions of those who may be held accountable for rare but potentially serious harmful events. We consider what changes may need to be enacted within secure and forensic mental health services to reduce the incidence and severity of consequent risks of harm to patients and their mental health recovery.

[Mental health and human rights: The experience of professionals in training with the use of mechanical restraints in Madrid, Spain]

Mechanical restraint is a coercive procedure in psychiatry, which despite being permitted in Spain, raises significant ethical conflicts. Several studies argue that non-clinical factors - such as professionals' experiences and contextual influences - may play a more important role than clinical factors (diagnosis or symptoms) in determining how these measures are employed. The aim of this study is to understand how the experiences of mental health professionals in training relate to the use of mechanical restraints in Madrid's mental health network. Qualitative phenomenological research was conducted through focus groups in 2017. Interviews were transcribed for discussion and thematic analysis with Atlas.ti. Descriptive results suggest that these measures generate emotional distress and conflict with their role as caregivers. Our findings shed light on different factors related to their experiences and contexts that are important in understanding the use of mechanical restraint, as well as the contradictions of care in clinical practice.

Exposure to workplace trauma for forensic mental health nurses: A scoping review

BACKGROUND

Forensic mental health is a challenging workplace, with nurses subject to various trauma exposures in their professional role.

OBJECTIVES

To identify the key concepts related to the nature, extent and impact of workplace trauma for forensic mental health nurses.

DESIGN

A scoping review, informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) tool.

METHODS

Sources of evidence were identified and assessed for inclusion using an explicit search strategy. Relevant information was extracted and synthesised to present a descriptive summary of existing evidence.

RESULTS

Of the 16 articles on workplace trauma for forensic mental health nurses included in the review, nine reported data related to extent (incidence and severity) and 14 described the impact. The incidence (per bed/per year) of each workplace trauma type ranged from 0.95 - 7.15 for physical violence, 0.39-5.12 for verbal abuse, 0.03-0.12 for sexual violence, and 1.47-7.9 for self-harming behaviour. The proportion of incidents at the lowest severity rating ranged from 15.1% to 84.7%, and the range for the highest severity rating was 0% to 38.7%. In the single study that examined the incidence of vicarious trauma, 14.9% reported low levels and 27.7% reported high levels. Psychological distress was the most commonly reported impact of workplace trauma, identified in eight studies. Seven studies reported limited data for physical injury from workplace trauma. The impacts of exposure to workplace trauma reported in the remaining studies included needing to access psychological support, experiencing physiological symptoms, feeling less safe at work, and requiring time off work. With the exception of two studies providing limited data related to absenteeism, the impact for organisations was not explored in existing literature.

CONCLUSIONS

While studies indicated that forensic mental health nurses are frequently exposed to various forms of workplace trauma, reports of severe assaults on staff were rare. Although limited, these findings suggest that cumulative exposure to workplace trauma over time, or exposure to more severe forms of physical violence, increase forensic mental health nurse vulnerability to experiencing detrimental impacts on their personal and professional wellbeing.

Dealing with care disruption in High and Intensive Care wards: From difficult patients to difficult situations

High and Intensive Care is a relatively new care model in Dutch mental health care for clinical admissions. One of the goals is to keep the admission short. For some patients, this goal is not realized, which results in a long-term admission. Often, this is experienced as a disruption. Disruptions in care processes are frequently defined in terms of patient characteristics. Yet, it may be that other factors play a role. The aim of this study is to gain better insight into the perceptions of care professionals of what is characteristic for disruptions at High and Intensive Care wards and how professionals can deal with these. Qualitative research was performed by means of semi-structured interviews and a focus group with professionals. Results show that a focus on patient characteristics is too narrow and that other factors also play an important role. These factors include challenges in the relation between professionals and the patient, a divided team, and a lack of collaboration with ambulatory care. In order to deal with these factors, professionals should invest in the relationship with the patient, identify destructive team processes early, and improve communication with ambulatory care. It is recommended to develop a monitoring tool that includes all these factors. Another recommendation is to organize structured reflection on dilemmas experienced in care. In conclusion, this study shows the importance of going beyond patient characteristics in order to better understand, identify, and deal with disruption at High and Intensive Care wards.

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

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

A hermeneutic phenomenological exploration of 'last resort' in the use of restraint

Restraining patients is a practice that dates back at least three centuries. In recent years, there has been a mandate and advocacy in various countries for organizations to shift towards the minimization of restraint, whereby its use is only as a 'last resort'. There is growing evidence internationally indicating the negative impact of the use of restraint. However, to date there is no research specifically focusing on trying to understand the concept of 'last resort'. Further insights to explore this concept among mental health nurses are therefore warranted. The empirical research comprised a hermeneutic phenomenological study. By recruiting and interviewing thirteen mental health nurses from across Canada who had experiences of restraint use, the research aimed to generate a deeper understanding of the meanings and lived experiences of the concept of 'last resort'. Data were collected through fifteen in-depth interviews. Data analysis was undertaken through a hermeneutic phenomenological framework based on van Manen's approach and Heideggerian philosophy. Five Heideggerian concepts were used to illuminate 'last resort' in restraint use by mental health nurses - temporality, inauthenticity, thrownness, leaping in and leaping ahead, and mood (fear). Key findings highlight the influence of nurses' past experiences, how nursing staff adopt a collective (rather than individual) approach, and the dependency on knowledge and skills of others in using restraint as a 'last resort'. Overall, the lived experience of 'last resort' is comprised of many elements. This study provides insights and an initial understanding, which is hoped to advance the field of restraint minimization.

Acute mental health nurses' experience of forcibly touching service users during physical restraint

Mental health nurses use forcible touch during physical restraint. Little research considers nurses' experiences and the meanings they give to forcible touch. This study investigated nurses' lived experiences of forcibly touching service users during physical restraint. A qualitative approach informed by phenomenology guided the study. The COREQ checklist ensured explicit and detailed reporting of the study. Fourteen nurses participated in semi-structured interviews analysed using a phenomenological process. The participants' experienced their touch during restraint as a problematic aspect of practice. They expressed preferences for holding different parts of the service user's body, described their proximity to the service user's body, and their experience of intimacy. The meanings of touch included forced, gentle, protective, and compassionate touches. Three themes revealed the complexity of this previously unproblematized area of nursing practice identified through their narratives. These were 'needing to justify', 'inconsistent knowing', and 'compassionate whilst careworn'. Physical restraint training requires reconceptualization towards touch to help nurses connect with the meanings of their bodily contact with service users, and the potential influence upon care. Articulation of these touch meanings will help to develop a nursing discourse on this neglected area of nursing practice. Training courses orientate primarily towards techniques, whilst nurses' conversations about touch are unclear. Training courses and practice fora can enhance understanding of the nursing contribution to physical restraint by addressing the nature of nurses' bodywork. This discourse will help to reveal the complexity of this touch intervention, identify areas of good practice, and areas for practice development.

Critical care nurses' experiences of nursing intoxicated patients after abuse of drugs

BACKGROUND

Patients intoxicated after abusing illicit drugs constitute a significant proportion of patients cared for in intensive care units. Intensive critical care nurses who nurse accidentally intoxicated patients face complex and demanding situations, and there is a lack of studies regarding this topic.

AIMS AND OBJECTIVES

To illuminate Swedish intensive critical care nurses' experiences of nursing accidentally intoxicated patients after abuse of illicit drugs.

DESIGN

A qualitative design with an inductive approach was used.

METHODS

Semi-structured interviews were conducted with eight intensive critical care nurses at an intensive care unit in Sweden. Data were analysed using qualitative content analysis.

FINDINGS

The themes found illuminate intensive critical care nurses' experiences of nursing accidentally intoxicated patients after their abuse of illicit drugs: feeling empathy and a wish to provide dignified care; dreading nursing the patient and feeling a lack of empathy; feeling frustration and questioning the care; lacking knowledge about a complex and challenging situation.

CONCLUSIONS

It is essential to respond to intoxicated patients with empathy and dignity. Intensive critical care nurses should learn how to identify factors that lead to provocation and agitation in order to reduce the occurrence of dangerous situations in intensive care units.

RELEVANCE TO CLINICAL PRACTICE

To create a caring environment where the interaction becomes more positive and harmonious, an intensive care nurse needs a deep understanding of what a drug abuse disorder means. Moreover, the ability to see the person behind the abuse and to provide non-judgemental support is required. WHAT IS KNOWN ABOUT THIS TOPIC Patients intoxicated after abuse of illicit drugs constitute a significant proportion of patients cared for in ICUs worldwide. Intensive critical nurses who nurse accidentally intoxicated patients face complex and demanding situations, and few studies have addressed this topic. WHAT THIS PAPER CONTRIBUTES It is essential to respond to intoxicated patients who are admitted to the ICU with empathy and dignity, as well as to learn how to identify factors that lead to provocation and agitation in order to reduce the occurrence of dangerous situations. Education is warranted and must be enhanced, including knowledge about drug abuse and training in communication and empathy Nursing should include an understanding of what the disease of drug abuse means and the development of the ability to see the person behind the abuse and to provide non-judgemental support.

International research into 22 years of use of chemical restraint: An evidence overview

BACKGROUND

Chemical restraint (CR) (also known as rapid tranquilisation) is the forced (non-consenting) administration of medications to manage uncontrolled aggression, anxiety, or violence in people who are likely to cause harm to themselves or others. Our population of interest was adults with mental health disorders (with/without substance abuse). There has been a growing international movement over the past 22 years towards reducing/eliminating restrictive practices such as CR. It is appropriate to summarise the research that has been published over this time, identify trends and gaps in knowledge, and highlight areas for new research to inform practice.

AIMS

To undertake a comprehensive systematic search to identify, and describe, the volume and nature of primary international research into CR published since 1995.

METHODS

This paper reports the processes and overall findings of a systematic search for all available primary research on CR published between 1 January 1996 and 31 July 2018. It describes the current evidence base by hierarchy of evidence, country (ies) producing the research, CR definitions, study purpose, and outcome measures.

RESULTS

This review identified 311 relevant primary studies (21 RCTs; 46 non-controlled experimental or prospective observational studies; 77 cross-sectional studies; 69 retrospective studies; 67 opinion pieces, position or policy statements; and 31 qualitative studies). The USA, UK, and Australia contributed over half the research, whilst cross-country collaborations comprised 6% of it. The most common research settings comprised acute psychiatric wards (23.3%), general psychiatric wards (21.6%), and general hospital emergency departments (19.0%).

DISCUSSION

A key lesson learnt whilst compiling this database of research into CR was to ensure that all papers described non-consenting administration of medications to manage adults with uncontrolled aggression, anxiety, or violence. There were tensions in the literature between using effective CR without producing adverse events, and how to decide when CR was needed (compared with choosing non-chemical intervention for behavioural emergencies), respecting patients' dignity whilst safeguarding their safety, and preserving safe workplaces for staff, and care environments for other patients. The range of outcome measures suggests opportunities to standardise future research.

Factors associated with physical injury or police involvement during incidents of workplace violence in hospitals: Findings from the first year of California's new standard

BACKGROUND

Workplace violence in healthcare settings is known to be a costly and often underreported problem. In California, hospitals are required to report incidents of violence towards workers to the California Occupational Safety and Health Administration (CalOSHA) using an online reporting system that went into effect in 2017.

METHODS

Reports submitted to CalOSHA from July 2017 to September 2018 pursuant to this new requirement were analyzed using descriptive methods and logistic regression.

RESULTS

Four hundred eight hospitals submitted reports using the new incident reporting system. Behavioral health units had 1.82 times the odds of the reported incident resulting in physical injury compared to inpatient medical units, and investor-owned facilities had 2.43 times the odds of the reported incident resulting in physical injury compared to city or county-owned facilities. Inpatient and behavioral health units had significantly reduced odds of a reported incident resulting in police involvement when compared to other locations within the hospital.

CONCLUSIONS

These findings indicate that protections for healthcare workers deserve ongoing attention from stakeholders and legislators and provide insight into how healthcare facilities report incidents of violence towards workers.

Aggression and Violence Toward Healthcare Workers in a Psychiatric Service in Italy: A Retrospective Questionnaire-Based Survey

Workplace violence and aggression are receiving increasing attention, especially when perpetrated in at-risk services such as psychiatric and emergency departments. Many healthcare providers have been victims of verbal aggressions (VAs) and physical aggressions (PAs), as well as injuries (INs), at the hands of patients. We conducted a 1-year retrospective questionnaire-based survey to assess workplace violence and aggression experienced by staff working at the Psychiatric Service of the Health District of Bolzano-Bozen (Italy). We performed parametric statistics. Logistic regression estimated the size of the association between PA occurrence and staff characteristics. Our psychiatric service's employees were frequent victims (91.5%) of 1 or more aggression/injury in the previous year. VAs and INs showed comparable frequencies among the three sites of our service, that is, the inpatient (INP), the outpatient (OUTP), and the rehabilitation (REHAB) units, differently from PAs, which were more common at INP (p < 0.001). The logistic regression model showed that female sex, working at INP, and a shorter psychiatry work experience predicted PAs occurrence. Most of the staff felt they could benefit from aggression management. Findings show that VAs, PAs, and INs are common among our psychiatric service's employees and point to the need to provide staff training on de-escalation.

Nonsuicidal Self-Injury: Management on the Inpatient Psychiatric Unit[Formula: see text]

BACKGROUND. Between 4% to 70% of inpatients engage in self-harming behaviors and effective interventions are needed to address this population. AIM. This article reviews literature from 2007 to 2017 to address treatment and management strategies specific for the treatment of nonsuicidal self-injury in the inpatient psychiatric setting. METHODS. Cochrane, PsycINFO, PubMed, and CINAHL were searched for relevant articles with 34 studies reviewed for applicability to the question, and 9 parsed into a summary of Findings table. RESULTS. Therapeutic approaches that show promise include cognitive behavioral therapy, dialectical behavior therapy, and mentalization as well as medications that act on the serotonergic, dopaminergic, and opioid systems. Effective models of care aim toward enhancing therapeutic relationships with staff, providers, and most important, encouraging the internal shift toward recovery within the patient. CONCLUSIONS. More research with controlled designs in the inpatient setting is needed, however, regardless of which approach is used, the impact of the individual caregiver on the patient's recovery is key.

Attributional styles of support staff working with people with intellectual disabilities exhibiting challenging behaviour

Background

Attributions are cognitive variables that influence a person's behaviour. Although a large volume of research has been conducted on the attributions of support staff with regard to challenging behaviour (CB) exhibited by people with intellectual disabilities (ID), studies on patterns of attributional dimensions (i.e. attributional styles) are scarce.

Method

Using semi‐structured interviews, 19 support staff members were asked to describe incidents of aggressive, self‐injurious and sexualized challenging behaviour. Data on attributions were analysed using the Leeds Attributional Coding System.

Results

Four attributional styles differed significantly for aggressive, self‐injurious and sexualized challenging behaviour. In addition, support staff members largely attributed these three types of CB to characteristics and behaviour of clients with ID.

Conclusions

The results indicate that it is important to train support staff to recognize and understand the ways in which their attributions and behaviour influence the existence and maintenance of CB.

Evaluating the impact of an electronic application of the Dynamic Appraisal of Situational Aggression with an embedded Aggression Prevention Protocol on aggression and restrictive interventions on a forensic mental health unit

Risk assessment is a pre-requisite for violence prevention in mental health settings. Extant research concerning risk assessment and nursing intervention is limited and has focused on the predictive validity of various risk assessment approaches and instruments, with few attempts to elucidate and test interventions that might prevent aggression, and reduce reliance on coercive interventions. The integration of risk assessment and violence prevention strategies has been neglected. The aim of this feasibility study was to test a novel Aggression Prevention Protocol designed to prioritize the instigation of less restrictive interventions on an acute forensic mental health unit for female patients. A prospective quasi-experimental study was designed to test an Aggression Prevention Protocol, linked to an electronic application of the Dynamic Appraisal of Situational Aggression (DASA). Following introduction of the DASA and Aggression Prevention Protocol, there were reductions in verbal aggression, administration of Pro Re Nata medication, the rate of seclusion, and physical and mechanical restraint. There was also an increase in documented nursing interventions. Overall, these results support further testing of the electronic application of the DASA and the Aggression Prevention Protocol.

The Impact of a Web-Based Course Concerning Patient Education for Mental Health Care Professionals: Quasi-Experimental Study

BACKGROUND

Continuing education has an important role in supporting the competence of health care professionals. Although Web-based education is a growing business in various health sectors, few studies have been conducted in psychiatric settings to show its suitability in demanding work environments.

OBJECTIVE

We aimed to describe the impact of a Web-based educational course to increase self-efficacy, self-esteem, and team climate of health care professionals. Possible advantages and disadvantages of the Web-based course are also described.

METHODS

The study used nonrandomized, pre-post intervention design in 1 psychiatric hospital (3 wards). Health care professionals (n=33) were recruited. Self-efficacy, self-esteem, and team climate were measured at 3 assessment points (baseline, 8 weeks, and 6 months). Possible advantages and disadvantages were gathered with open-ended questions at the end of the course.

RESULTS

Our results of this nonrandomized, pre-post intervention study showed that health care professionals (n=33) had higher self-efficacy after the course, and the difference was statistically significant (mean 30.16, SD 3.31 vs mean 31.77, SD 3.35; P=.02). On the other hand, no differences were found in the self-esteem or team climate of the health care professionals before and after the course. Health care professionals found the Web-based course useful in supporting their work and relationships with patients. The tight schedule of the Web-based course and challenges in recruiting patients to use the patient education program with health care professionals were found to be the disadvantages.

CONCLUSIONS

Web-based education might be a useful tool to improve the self-efficacy of health care professionals even in demanding work environments such as psychiatric hospitals. However, more studies with robust and sufficiently powered data are still needed.

The physical and mental health of acute psychiatric ward staff, and its relationship to experience of physical violence

To evaluate and describe the physical and mental health of staff on acute psychiatric wards and examine whether violence exposure is linked with health status. We undertook a cross-sectional survey with 564 nursing staff and healthcare assistants from 31 psychiatric wards in nine NHS Trusts using the SF-36, a reliable and valid measure of health status and compared summary scores with national normative data. Additional violence exposure data were collated simultaneously and also compared with health status. The physical health of staff was worse, and their mental health was better than the general population. Physical health data were skewed and showed a small number of staff in relatively poor health while the majority were above average. Better physical health was associated with less time in the current post, a higher pay grade, and less exposure to mild physical violence in the past year. Better mental health was associated with being older and from an ethnic minority background. Violence exposure influenced physical health but not mental health when possible confounders were considered. Mental health was strongly influenced by ethnicity, and further research might highlight the impact on own-group ethnic density on the quality of care. The impact of staff whom are physically unwell or impaired in the workplace needs to be considered as the quality of care may be compromised despite this being an example of inclusiveness, equal opportunities employment, and positive staff motivation.

People who experience seclusion in adult mental health inpatient services: An examination of health of the nation outcome scales scores

The Health of the Nation Outcomes Scales (HoNOS) provides an overview of a person's behaviour, impairment, clinical symptoms, and social functioning. This study investigated the profile of people who had been secluded in New Zealand's adult mental health inpatient services using 12 individual HoNOS ratings. Routinely collected clinical data were extracted from the Programme for the Integration of Mental Health Data (PRIMHD). This is the national data set for mental health and addiction services. A logistic regression model was fitted to the data which adjusted for age, sex, ethnicity, bed nights, compulsory treatment, and district health board. After adjustment, three HoNOS items significantly predicted the risk of seclusion: overactive, aggressive, disruptive, or agitated behaviour (adjusted OR = 4.82, 95% CI [3.88, 5.97], P < 0.001); problem drinking or drug-taking (adjusted OR = 1.51, 95% CI [1.25, 1.82], P < 0.001); and problems with hallucinations and delusions (adjusted OR = 1.33, 95% CI [1.09, 1.63], P = 0.006). In addition, two HoNOS items were protective for seclusion: nonaccidental self-injury (adjusted OR = 0.65, 95% CI [0.51, 0.83], P < 0.001) and depressed mood (adjusted OR = 0.58, 95% CI [0.47, 0.72], P < 0.001). Thus, responding effectively to agitation and/or aggression, substance use, and psychosis plays an important role in reducing the use of seclusion. Mental health nurses and other workers can reduce seclusion through early assessment, effective communication, de-escalation techniques, reduction tools, trauma-informed care, and consulting with consumers and whānau.

Prevalence of workplace violent episodes experienced by nurses in acute psychiatric settings

Nurses who experience workplace violence exhibit compromised care quality and decreased work morale, which may increase their turnover rate. This study explored prevalence of workplace violence, the reaction of victims, and workplace strategies adopted to prevent violence among acute psychiatric settings in northern Taiwan. A cross-sectional study was conducted, which consisted of 429 nurses who completed the Chinese version of the Workplace Violence Survey Questionnaire developed by the International Labor Office, International Council of Nurses, World Health Organization, and Public Services International. The rates of physical and psychological violence were 55.7% and 82.1%, respectively. Most perpetrator of the workplace violence were patients. Most victims responded by instructing the perpetrator to stop, followed by narrating the incident to friends, family, and colleagues. Only 4.9%–12% of the victims completed an incident or accident form, and the main reason for not reporting these violent incidents was the belief that reporting such incidents was useless or unimportant. The major strategies adopted by workplaces to prevent violence were security measures, patient protocols, and training. Institutions should train staff to handle violence, provide a therapeutic environment, simplify the reporting process, and encourage reporting of all types of violence.

Narrative Case Notes Have the Potential to Predict Seclusion 3 Days in Advance: A Mixed-Method Analysis

Objectives: Current risk assessment tools can predict problematic behavior and the need for coercive measures, but only with a moderate level of accuracy. The aim of this study was to assess antecedents and triggers of seclusion. Methods: Narrative notes of health care professionals on psychiatric inpatients were analyzed daily starting 3 days prior to seclusion in the case group (n = 26) and compared to a matched control group without seclusion (n = 26) by use of quantitative and qualitative research methods, based on qualitative content analysis. Results: Quantitative measures showed more aggression in the case group with highly significant differences between the groups (p < 0.001) at all measurement times. Seclusion was significantly associated with the total word count of the narrative notes. Subjective emotional expressions by staff were more apparent before seclusion (p = 0.003). Most frequently, subjective expressions regarding "arduous/provocative" (p < 0.001) and "anxious" (p = 0.010) sentiments could be identified in the case group. Description of patients' behavior in the case group included more negatively assessed terms (p = 0.001). Moreover, sleep loss, refusing medication, high contact frequency, demanding behavior and denied requests were present in a significantly higher frequency before seclusion. Expressions like "threatening" (p = 0.001) were found only before seclusion and appeared to have the function of personal risk assessment. The expression "manageable" (p = 0.035) appeared often in difficult situations that could still be handled. Conclusion: Several factors preceding seclusion could be identified. Narrative notes of staff already showed differences 3 days before the escalation. Particularly the word count, the analysis of terms describing patients' behavior, subjective expressions of staff, and terms used as a function of personal risk assessment could help to provide better predictions of aggressive incidents and to prevent coercive measures.

Identifying Violent Behavior Using the Oxford Mental Illness and Violence Tool in a Psychiatric Ward of a German Prison Hospital

Background: Although there is evidence that individuals who suffer from severe mental disorders are at higher risk for aggressive behavior, only a minority eventually become violent. In 2017, Fazel et al. developed a risk calculator (Oxford Mental Illness and Violence tool, OxMIV) to identify the risk of violent crime in patients with mental disorders. For the first time, we tested the predictive validity of the OxMIV in the department of psychiatry at the prison hospital in Berlin, Germany, and presented findings from our internal validation. Materials and Methods: We designed a cohort study with 474 patients aged 16-65 years old who met the inclusion criteria of schizophrenia-spectrum or bipolar disorder and classified the patients into two groups: a violent group with 191 patients and a nonviolent group with 283 patients. Violence was defined as the aggressive behavior of a patient with the necessity of special observation. We obtained all the required information retrospectively through patient files, applied the OxMIV tool on each subject, and compared the results of both groups. Sensitivity, specificity, and positive/negative predictive values were determined. We used logistic regression including variable selection and internal validation to identify relevant predictors of aggressive behavior in our cohort. Results: The OxMIV score was significantly higher in the violent group [median 4.21%; Interquartile range (IQR) 8.51%] compared to the nonviolent group (median 1.77%; IQR 2.01%; p < 0.0001). For the risk of violent behavior, using the 5% cutoff for "increased risk," the sensitivity was 44%, and the specificity was 89%, with a positive predictive value of 72% and a negative predictive value of 70%. Applying logistic regression, four items were statistically significant in predicting violent behavior: previous violent crime (adjusted odds ratio 5.29 [95% CI 3.10-9.05], p < 0.0001), previous drug abuse (1.80 [1.08-3.02], p = 0.025), and previous alcohol abuse (1.89 [1.21-2.95], p = 0.005). The item recent antidepressant treatment (0.28 [0.17-0.47]. p < 0.0001) had a statistically significant risk reduction effect. Conclusions: In our opinion, the risk assessment tool OxMIV succeeded in predicting violent behavior in imprisoned psychiatric patients. As a result, it may be applicable for identification of patients with special needs in a prison environment and, thus, improving prison safety.

Degree of Anger During Anger-Generating Situations Among Psychiatric Staff Nurses: Association Between Nurses' Attitudes Toward Service Users' Aggression and Confidence in Intervening in Aggressive Situations

Some situations require psychiatric staff nurses to respond to service users' negativity or aggression. As a result, psychiatric staff nurses may experience anger. The current study examined how anger levels of psychiatric staff nurses triggered by anger-generating situations by service users affected nurses' confidence and attitudes. A questionnaire survey was administered among 386 psychiatric staff nurses. The questionnaire surveyed anger levels in anger-generating situations, aggressiveness, nurses' attitudes toward aggression, and self-efficacy of intervening in aggressive situations. Path analysis revealed differences between male and female nurses. Male nurses' anger in response to physical aggression was mild when they were confident in handling aggression. Furthermore, female nurses who had high confidence in intervening in an aggressive situation had low anger levels. Confidence in intervening in aggressive situations appeared to dissipate anger and ease nurses during aggressive interactions. [Journal of Psychosocial Nursing and Mental Health Services, 56(9), 51-59.].

Blurred Boundaries – A Qualitative Study of How Acts of Self-Harm and Attempted Suicide Are Defined by Mental Health Practitioners

Abstract. Background: There is no commonly accepted definition of the term self-harm, and there is an ongoing debate about whether or not it should include acts of attempted suicide. The use of this language in clinical practice has not previously been explored. Aims: To investigate if, and how, practitioners distinguish between acts of self-harm and attempted suicide, and present any implications for practice. Method: We conducted semistructured interviews with a random sample of 18 frontline practitioners from 10 mental health wards and completed a thematic analysis of interview data. Results: Most participants described self-harm and attempted suicide as distinct behaviors. Characteristics of the act, disclosures of intent, and the level of distress observed were commonly used to differentiate between self-harm and attempted suicide. Very few participants believed that people who self-harm may also feel suicidal. Practitioners confidently described two different behaviors, yet self-harm and attempted suicide were often conflated, revealing the challenges and complexities associated with the separation of these acts in clinical practice. Limitations: Clinicians working in other settings or disciplines may have different views. Participants' accounts may not be an accurate representation of what happens in practice. Conclusion: This study adds to a body of evidence which argues against the dichotomous separation of these behaviors into acts of suicidal and nonsuicidal self-harm.Our findings suggest there is no common understanding of the boundaries between self-harm and attempted suicide among frontline clinicians. The language currently used, and consequent practice, particularly with regard to risk assessment, is problematic. Efforts should be made to operationalize terms around suicidal behavior and to incorporate these into training for clinical staff.

An integrative review exploring the physical and psychological harm inherent in using restraint in mental health inpatient settings

In Western society, policy and legislation seeks to minimize restrictive interventions, including physical restraint; yet research suggests the use of such practices continues to raise concerns. Whilst international agreement has sought to define physical restraint, diversity in the way in which countries use restraint remains disparate. Research to date has reported on statistics regarding restraint, how and why it is used, and staff and service user perspectives about its use. However, there is limited evidence directly exploring the physical and psychological harm restraint may cause to people being cared for within mental health inpatient settings. This study reports on an integrative review of the literature exploring available evidence regarding the physical and psychological impact of restraint. The review included both experimental and nonexperimental research papers, using Cooper's (1998) five-stage approach to synthesize the findings. Eight themes emerged: Trauma/retraumatization; Distress; Fear; Feeling ignored; Control; Power; Calm; and Dehumanizing conditions. In conclusion, whilst further research is required regarding the physical and psychological implications of physical restraint in mental health settings, mental health nurses are in a prime position to use their skills and knowledge to address the issues identified to eradicate the use of restraint and better meet the needs of those experiencing mental illness.

A pilot study of "post-seclusion and/or restraint review" intervention with patients and staff in a mental health setting

PURPOSE

To develop and evaluate a "post-seclusion and/or restraint review" (PSRR) intervention implemented in an acute psychiatric care unit.

DESIGN AND METHODS

Twelve staff members and three patients were enrolled in a participatory case study. To evaluate PSRR intervention, qualitative analysis was carried out. Seclusion and restraint use 6 months before and after the PSRR implementation was compared.

FINDINGS

Nurses reported that they were able to explore the patient's feelings during the PSRR intervention with patients, which led to restoration of the therapeutic relationship. PSRR with the treatment team was perceived as a learning opportunity, which allowed to improve the therapeutic intervention. Both the use of seclusion and the time spent in seclusion were significantly reduced 6 months after the implementation of PSRR intervention.

PRACTICE IMPLICATION

Our results suggest the efficacy of PSRR in overcoming the discomfort perceived by both staff and patient and, in the meantime, in reducing the need for coercive procedures. Systematic PSRR could permit to improve the quality of care and the safety of aggressiveness management.

The Impact of 'Being There': Psychiatric Staff Attitudes on the Use of Restraint

The practice of mechanically restraining psychiatric patients is constantly under debate, and staff attitudes are considered a central factor influencing restraining practices. The aim of this study was to explore associations between psychiatric staff members' presence and participation in incidences of restraint and attitudes towards mechanical restraints.

METHODS

Staff members (psychiatrists, nurses, paramedical staff; N = 143 working in a government psychiatric hospital in Israel) completed a questionnaire including personal information, participation in incidents of restraint and attitudes towards mechanical restraints. Items were categorized into the following categories: security and care; humiliation and offending; control; order; education and punishment.

RESULTS

Compared to those who were not present during restraint, staff members who were present agreed significantly less with statements indicating that restraints are humiliating and offending and agreed more with statements indicating that restraints are used primarily for security and care (p < .05). Among those present in incidences of restraint, staff members who physically participated in restraint agreed significantly more with statements indicating that restraints are a means for security, care and order, and less with statements indicating restraints are humiliating and offending, compared to those present but not physically participating in restraint (p < .05).

CONCLUSIONS

These findings highlight the importance of proximity of staff members to incidences of restraints. This may have implications in understanding the professional and social discourse concerning mechanical restraints.

[Seclusion and restraint: From prescription to decision]

Psychiatric care has always included patients in crisis who are potentially dangerous or agitated. Faced with the many issues they may encounter, the therapeutic relationship has always been prioritized over all other considerations. However, the practice of seclusion and restraint has been steadily increasing in the past few decades. Their use is becoming customary rather than exceptional and consequently fosters less thought by the care teams. In the Healthcare System Modernization Act of January 26th, 2016, the lawmakers sought to underline the freedom-destroying nature of these practices and the necessity of their regulation. This law represents a fundamental change in the nature of seclusion and restraint. What was but a simple prescription becomes a conscious decision of depriving someone of her or his freedom and must only be considered as a last resort. The changes in the Law and the recent changes in the recommendations for clinical practice by the French National Institute of Health invite reflection. Many questions remain about the origins of violence, the reasons for the increasing use of seclusion and restraint measures, and the alternatives that have been developed. Many theories suggest that the less stressful and constrained an environment is, the more empowered the patient will be. He is an actor in his own care and is considered a full active participant. The Law is reconciled with caregivers initiating a reflection on the benefits of these measures regarding the violation of fundamental freedoms. Reflection on psychiatric care and the quality of its management must be the focus when caring for patients in crisis.

Structured risk assessment for reduction of multiple risk outcomes in a secure mental health setting: Use of the START

BACKGROUND

Structured risk assessment is commonly used in secure settings to aid prediction and prevention of risky behaviours; the expected benefits have rarely been investigated.

AIMS

The aim of the study is to determine whether adverse outcomes (physical and verbal aggression, self-harm, victimisation, self-neglect, unauthorised leave and substance abuse) reduced after patients were assessed with the Short-term Assessment of Risk and Treatability (START).

METHODS

In a naturalistic study, anonymised demographic and clinical information was collected from 50 male patients. Data included START assessment and frequency of target behaviour for 3 months before and after first assessment. Chi-square and linear mixed models analyses were used to determine whether there was any change in the behaviours of interest.

RESULTS

There were no significant changes in physical or verbal aggression over time, although a tendency towards fewer incidents was apparent. Other adverse behaviours were very infrequent at baseline, precluding adequate analysis.

CONCLUSIONS

In this small sample, START did not achieve its primary purpose of significant reduction in adverse behaviours. Although our sample size was informed by a power calculation, we may have over-estimated the size of anticipated change. Further, the 3-month comparison periods before and after the assessment follow-up period were rather short. Accordingly, we recommend more research on the value of this tool in practice rather than discontinuing its use. Copyright © 2017 John Wiley & Sons, Ltd.

Empathic processes during nurse-consumer conflict situations in psychiatric inpatient units: A qualitative study

Empathy is a central component of nurse-consumer relationships. In the present study, we investigated how empathy is developed and maintained when there is conflict between nurses and consumers, and the ways in which empathy can be used to achieve positive outcomes. Through semistructured interviews, mental health nurses (n = 13) and consumers in recovery (n = 7) reflected on a specific conflict situation where they had experienced empathy, as well as how empathy contributed more generally to working with nurses/consumers. Thematic analysis was used to analyse the data, utilizing a framework that conceptualizes empathy experiences as involving antecedents, processes, and outcomes. The central theme identified was 'my role as a nurse - the role of my nurse'. Within this theme, nurses focussed on how their role in managing risk and safety determined empathy experienced towards consumers; consumers saw the importance of nurse empathy both in conflict situations and for their general hospitalization experience. Empathy involved nurses trying to understand the consumer's perspective and feeling for the consumer, and was perceived by consumers to involve nurses 'being there'. Empathic relationships built on trust and rapport could withstand a conflict situation, with empathy a core component in consumer satisfaction regarding conflict resolution and care. Empathy allows the maintenance of therapeutic relationships during conflict, and influences the satisfaction of nurses and consumers, even in problematic situations. Nurse education and mentoring should focus on nurse self-reflection and building empathy skills in managing conflict.