Clients with mental health problems who sexualize the nurse-client encounter: the nursing discourse

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

Background

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

Objectives

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

Design

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

Setting

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

Participants

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

Interventions

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

Main outcome measures

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

Results

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

Conclusions

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

Limitations

Uncontrolled design and self-selecting sample.

Future work

Definitive trial determining intervention effects.

Trial registration

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

Funding

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

Context

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

The gray zone of patient-nurse communication: Inappropriate sexual behavior

PURPOSE

This review was written to examine the incidences of inappropriate sexual behavior (ISB) and to study the responsibilities of nurses in the management of ISB.

CONCLUSIONS

When nurses experience ISB, they tend to describe this situation as harassment. However, the use of the phrase "harassment" indicates inadequate professionalism because although disturbing, not every incidence of ISB is an expression of adult sexuality. Some patients are also likely to use this type of behavior to mask their existing life stress. As a result, nurses have difficulty interpreting and managing behavior that falls in this gray zone.

PRACTICE IMPLICATIONS

To support nurses, we recommended that studies that define ISB, determine its prevalence, evaluate it, and guide nurses in the management of ISB should be carried out.

Physical Therapist, Physical Therapist Assistant, and Student Response to Inappropriate Patient Sexual Behavior: Results of a National Survey

BACKGROUND

A recent survey found that 84% of physical therapist, physical therapist assistant, and student respondents experienced inappropriate patient sexual behavior (IPSB) over their careers and 47% over the prior 12 months. Prevalence data justify consideration of how to address IPSB.

OBJECTIVE

The objective was to determine how physical therapist clinicians (used here to mean physical therapists, physical therapist assistants, and students) address IPSB and examine strategy impact.

DESIGN

The design was observational and cross-sectional.

METHODS

Several sections of the American Physical Therapy Association and selected education programs fielded the electronic survey. Respondents reported on the frequency and effect of IPSB response strategy. Response-strategy impact was tested for statistical significance. Open-ended comments were analyzed using qualitative methods.

RESULTS

Of 1027 respondents, 396 had experienced IPSB over the prior 12 months; 391 provided data on the frequency and effect of response strategies used. Common informal responses included distraction, ignoring IPSB, and altering treatment to avoid physical contact or being alone. Common formal responses included reporting the behavior within the facility and documenting the behavior. Successful strategies included distraction, avoidance, direct confrontation, behavioral contracts, transfer of care, and chaperone use. Experienced clinicians were more likely to be direct, whereas novice clinicians were more likely to engage in unsuccessful actions of ignoring and joking.

LIMITATIONS

Limitations included self-report, clinician memory, and convenience sampling.

CONCLUSIONS

The first findings in 20 years on physical therapist, physical therapist assistant, and student response to IPSB provide direction for the profession. Results indicate a need for clear workplace policies coupled with training for managers and supervisors to support clinicians in resolving IPSB. Policies on using behavioral contracts, chaperones, and transfer of care could empower staff to consider these successful options. Professional education and training for all physical therapy professionals on assertive communication and redirection strategies with IPSB appears warranted.

Prevalence and Risk of Inappropriate Sexual Behavior of Patients Toward Physical Therapist Clinicians and Students in the United States

BACKGROUND

For health care providers in the United States, the risk for nonfatal violence in the workplace is 16 times greater than that for other workers. Inappropriate patient sexual behavior (IPSB) is directed at clinicians, staff, or other patients and may include leering, sexual remarks, deliberate touching, indecent exposure, and sexual assault. Inappropriate patient sexual behavior may adversely affect clinicians, the organization, or patients themselves. Few IPSB risk factors for physical therapists have been confirmed. The US prevalence was last assessed in the 1990s.

OBJECTIVE

The objectives of this study were to determine career and 12-month exposure to IPSB among US physical therapists, physical therapist assistants, physical therapist students, and physical therapist assistant students and to identify IPSB risk factors.

DESIGN

This was a retrospective and observational study.

METHODS

An electronic survey was developed; content validity and test-retest reliability were established. Participants were recruited through physical therapist and physical therapist assistant academic programs and sections of the American Physical Therapy Association. Inappropriate patient sexual behavior risk models were constructed individually for any, mild, moderate, and severe IPSB events reported over the past 12 months. Open-ended comments were analyzed using qualitative methods.

RESULTS

Eight hundred ninety-two physical therapist professionals and students completed the survey. The career prevalence among respondents was 84%, and the 12-month prevalence was 47%. Statistical risk modeling for any IPSB over the past 12 months indicated the following risks: having fewer years of direct patient care, routinely working with patients with cognitive impairments, being a female practitioner, and treating male patients. Qualitative analysis of 187 open-ended comments revealed patient-related characteristics, provider-related characteristics, and abusive actions.

LIMITATIONS

Self-report, clinician memory, and convenience sampling are limitations of this type of survey research.

CONCLUSIONS

The extremely high prevalence of IPSB among physical therapist professionals warrants practitioner and student education as well as clear workplace policy and support.

Sexual behaviours on acute inpatient psychiatric units

The purpose of the study was to assess the types and frequency of sexual behaviours displayed by patients during the first 2 weeks of admission to acute psychiatric units and what relationship these have to other challenging patient behaviours. The method used was a survey of sexual behaviours, conflict and containment events carried out by 522 patients during the first 2 weeks of admission in 84 wards in 31 hospitals in the South East of England. Incidents of sexual behaviour were common, with 13% of patients responsible for at least one incident. Although exposure was the most frequent of these behaviours, non-consensual sexual touching, was instigated by 1 in 20 patients. There were no differences in the numbers of sexual events between single sex and mixed gender wards. Few associations were found with the demographic features of perpetrators, although all those engaging in public masturbation were male, and male patients were more likely to sexually touch another without their consent. Single sex wards do not seem to necessarily offer significant protection to potentially vulnerable victims. Perpetrators do not seem to be predictable in advance, nor was there any common set or pattern of disruptive behavioural events indicating that a sexual incident was about to occur.

The sexual and relationship needs of people who experience psychosis: quantitative findings of a UK study

Few studies have investigated the experiences of people regarding sexual and relationship issues in the area of mental health. This study presents the quantitative findings of a larger study that was conducted in London, UK. The aims of the study were to establish client's sexual and relationship experiences and perceived needs. A total of 30 people with a medical diagnosis of schizophrenia, living in the community, were interviewed using three questionnaires. The first related to demographics, the second used relevant parts of the Camberwell Assessment of Need (CAN) and the third looked at possible determinants of sexual behaviour. The CAN also captured keyworker responses to issues related to their clients sexual and relationship requirements. The results showed that 83% of the clients were currently experiencing sexual feelings. Some 90% of clients felt some need in relation to sexual expression and 83% for needs related to intimate relationships. Only 10% of staff recognized sexual expression as a need in clients in their care and 43% perceived a need for intimate relationships. Furthermore, most clients interviewed thought that their psychotropic medication caused sexual problems. Contrasts are made with other studies to help highlight the important issues that emerged for service users.

Investigating mental health service user views regarding sexual and relationship issues

To date, very few empirical studies exist that investigate sexual and relationship issues and people who experience enduring mental health problems and less attention has been paid to the personal accounts of clients in this respect. The present study, carried out in the UK, involved 30 people who were asked about past and present relationship experiences and elicited hopes and aspirations for future sexual and relationship needs. A semi-structured interview schedule was constructed that specifically addressed potential sexual and relationship concerns and was conducted face-to-face. The aim was to capture in-depth perspectives of people with a medical diagnosis of schizophrenia regarding intimate relationships. The results of the study showed that people are willing and able to articulate thoughts, feeling and beliefs in the area. The findings are presented, and the implications in terms of mental health practice, education and research are discussed.