A qualitative investigation into nurses' perceptions of factors influencing staff injuries sustained during physical interventions employed in response to service user violence within one secure learning disability service

The Development and Acceptability of a Comprehensive Crisis Prevention Program for Implementation in Health Care Settings

INTRODUCTION

Behavioral crises are increasingly prevalent in health care settings. Existing programs, however, include procedures that lack adaptability, omit critical components, and deviate from clinical best-practice recommendations. Health care employees also continue to report lacking confidence for safely managing behavioral crises.

AIMS

We described the development and acceptability of a comprehensive crisis prevention program and its modification for a large pediatric health care system to help remediate the limitations of existing programs.

METHOD

Chi-square analyses evaluated the acceptability of the crisis prevention program pre- versus post-training and at 3- and 6-month follow-up times. For insignificant outcomes, logistical regressions identify whether responses differed between emergency-department and nonemergency-department employees.

RESULTS

Chi-square analyses were significant for 10 of 15 questions suggesting that employees were more confident in managing and communicating during behavioral crises post-training, and that this confidence was maintained. Logistic regressions found that emergency-department employees differed in some responses to the acceptability questionnaire than nonemergency-department employees over time.

CONCLUSION

The present crisis prevention program is adaptable to various settings and patients, and it is well received overall by employees. The safety of patients and employees is integral to the delivery of quality care and improving patient-provider relations.

Understanding the contribution of intellectual disabilities nurses: Paper 3 of 4 - evaluation

The overall objective of this research was to identify intellectual disability nursing interventions and their impact on the health and healthcare of people with intellectual disability. This is part 3 of a 4-part series. In this paper we report the findings from quantitative questions from an online survey of intellectual disability nurses. The objective of this part of the study was to a evaluate intellectual disability nurses' confidence in their understanding of the interventions they undertook. Quantitative data was collected using an online survey questionnaire from a voluntary response and snowball sample of 230 participants from 7 countries. Thematic, descriptive statistical, and inferential statistical analyses were undertaken. The evaluation data suggest and demonstrate a lack of clarity among intellectual disability nurses of the interventions they can effectively undertake. There appears to be correlations between lack of role clarity and the types of employer organisations and countries. Further work need to be undertaken by nurse leaders ascertain and address this lack of clarity.

A Quality Improvement Project to Reduce Events of Visitor Escalation in the Intensive Care Nursery

BACKGROUND

Escalating and aggressive visitor behaviors have become increasingly common in healthcare settings nationally, negatively impacting staff and patients alike. Most healthcare providers do not innately possess the specific skills to manage such behaviors. Management of escalating and aggressive behaviors presents a particularly bedeviling challenge when staff safety must be balanced with the needs of parent-neonate bonding.

PURPOSE

In the Intensive Care Nursery (ICN), the frequency of aggressive and hostile incidents from visitors increased such that the staff felt frustrated by and uneasy about their work environment.

METHODS

The ICN convened an interprofessional team to strategize interventions aimed at consistently managing aggressive behavior and supporting the staff after aggressive and/or hostile visitor encounters.

FINDINGS

Following staff education and training, the unit launched a de-escalation management algorithm in July 2018 that assisted in identifying high-risk families at admission and drove consistent action and management of all visitor behaviors. In the 12 months following the intervention, the frequency of behavioral escalation decreased by 75% and staff perception of safety increased by 25%.

IMPLICATIONS FOR PRACTICE

Collaborating with staff to design consistent strategies to manage aggressive and escalating visitor behavior can improve safety and improve employee satisfaction in the ICN.

IMPLICATIONS FOR RESEARCH

Additional research on the effectiveness of the algorithm in other ICNs and alternative areas of practice is needed. Furthermore, validation of a staff perception survey measuring the impact of escalating visitor behaviors on employees would be an important next step in this research.Video abstract available athttps://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?autoPlay=false&videoId=43.

Conceptual framework for a comprehensive competence in managing challenging behaviour: The views of trained instructors

WHAT IS KNOWN ON THE SUBJECT?: There is body of knowledge available about the harms associated with restrictive interventions used in behaviour management, service users' perceptions of the use of restraints, and staff competence in behaviour management. The staff perspective has been studied in terms of staff exposure, responses to and prevention of aggression, staff-related factors associated with service user aggression, and staff attitudes and perceptions towards violence. The definitions of competence in behaviour management provided in training interventions are fragmented and based on unilateral measurements. Training interventions with the purpose of enhancing staff competence in behaviour management are organized regularly, yet there is a lack of clarity on how effective these interventions are. Inadequate conceptual understanding of behaviour management can weaken the effectiveness of these interventions. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Our study produced new knowledge by providing a preliminary conceptual framework that can be used to comprehensively describe and assess competence in managing challenging behaviour and to cover safely the whole care process. Humane care and ethical sensitivity should be the premises of interaction with people in distress. We also pointed out the needs for conceptual clarification of the concepts of confidence, support and restraint. We provide important new insight into the leadership and cultural issues of behaviour management that is relevant for patients, staff members and healthcare organizations. We found that staff members do not consider service user safety and workplace safety as opposing issues. Further, we provide new perspectives for prevention, the risk assessment process and effective communication in the context of behaviour management. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: A comprehensive understanding of the competences related to behaviour management will foster universal definitions for "support" and "restraint," which can then be used to ensure that the best practices are used for behaviour management. Organizational culture and participative leadership on behaviour management should be developed with a special focus on safety issues, common understanding of comprehensive competence, risk assessment and prevention, views regarding the use of restraints, and teamwork. ABSTRACT: Introduction Previous research concerning staff views of behaviour management has not considered instructors' views. The definitions of competence in behaviour management are fragmented, which can undermine the effectiveness of training interventions. Aim/Question This study aimed to describe Finnish and British Management of Actual or Potential Aggression instructors' perceptions of safety and behaviour management-related competences and create a conceptual framework for comprehensive competence. Method An explorative-descriptive qualitative approach with purposive sampling (N = 22), semi-structured interviews and abductive content analysis. Results Conceptual framework of comprehensive competence in managing challenging behaviour includes five categories-knowledge, skills, attitude, confidence and ethical sensitivity-and 21 subcategories. Competent staff and supportive leadership ensured safety, while inconsistent risk management culture, the health and behaviour of service users, and inadequate staff orientation endangered safety. Discussion The study produced new knowledge of safety issues and competences from the perspective of the instructors who deliver behaviour management training. Implications for practice Competence to manage challenging behaviour should be developed based on our conceptual framework to provide an effective and safe training. Prevention, the risk assessment process, alternative communication, and the definitions of "confidence," "support" and "restraint" should all be sufficiently addressed in future training.

Relationships between medical incidents, clinical competency, and clinical experience in child and adolescent psychiatric in-patient nursing: A structural equation modeling approach

PROBLEM

Psychiatric nurses experience medical incidents, including potential errors and adverse incidents. We aimed to identify the elements of clinical competency related to medical incidents and to test the hypothesized relationships between medical incidents, clinical competency, and clinical experience.

METHODS

A self-administered survey was conducted among 406 nurses working in child and adolescent psychiatric wards at 29 Japanese hospitals.

FINDINGS

Medical incidents were significantly negatively correlated with two competencies-collecting client information and solving potential problems-and significantly positively correlated with the competency of collaboration with team members.

CONCLUSIONS

Our hypothesis was partially supported, suggesting that medical incidents involve various factors other than nurses' clinical competency.

[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.

Nurses' perceptions of risks for occupational hazards in patient seclusion and restraint practices in psychiatric inpatient care: A focus group study

Seclusion and restraint are regularly used to manage patient aggression events in psychiatric inpatient care, despite occupational safety concerns. There is currently a lack of information on how nurses perceive the use of patient seclusion and restraint as a risk for occupational safety. The aim of this study is to describe the risks for occupational hazards in patient seclusion and mechanical restraint practices as well as ideas for improvement identified by nurses. A qualitative descriptive design was adopted, using focus groups comprising nurses (N = 32) working in psychiatric inpatient care. The data were analysed using inductive content analysis, and the results were reported using the consolidated criteria for reporting qualitative studies (COREQ). Four themes of risk for occupational hazards were identified: patient-induced, staff-induced, organization-induced, and environment-induced risks. One significant finding was that nurses described that their actions can strongly contribute to occupational hazards during seclusion and mechanical restraint practices. The nurses gave various ideas for how occupational safety could be improved during seclusion and mechanical restraint events, ideas involving staff, the organization, and environmental enhancements.

Patient safety in inpatient mental health settings: a systematic review

OBJECTIVES

Patients in inpatient mental health settings face similar risks (eg, medication errors) to those in other areas of healthcare. In addition, some unsafe behaviours associated with serious mental health problems (eg, self-harm), and the measures taken to address these (eg, restraint), may result in further risks to patient safety. The objective of this review is to identify and synthesise the literature on patient safety within inpatient mental health settings using robust systematic methodology.

DESIGN

Systematic review and meta-synthesis. Embase, Cumulative Index to Nursing and Allied Health Literature, Health Management Information Consortium, MEDLINE, PsycINFO and Web of Science were systematically searched from 1999 to 2019. Search terms were related to 'mental health', 'patient safety', 'inpatient setting' and 'research'. Study quality was assessed using the Hawker checklist. Data were extracted and grouped based on study focus and outcome. Safety incidents were meta-analysed where possible using a random-effects model.

RESULTS

Of the 57 637 article titles and abstracts, 364 met inclusion criteria. Included publications came from 31 countries and included data from over 150 000 participants. Study quality varied and statistical heterogeneity was high. Ten research categories were identified: interpersonal violence, coercive interventions, safety culture, harm to self, safety of the physical environment, medication safety, unauthorised leave, clinical decision making, falls and infection prevention and control.

CONCLUSIONS

Patient safety in inpatient mental health settings is under-researched in comparison to other non-mental health inpatient settings. Findings demonstrate that inpatient mental health settings pose unique challenges for patient safety, which require investment in research, policy development, and translation into clinical practice.

PROSPERO REGISTRATION NUMBER

CRD42016034057.

A Systematic Process for Selection of a Crisis Prevention/De-Escalation Training Program in the Hospital Setting

INTRODUCTION: The current de-escalation program utilized in this organization was not adequately meeting the needs of all the pediatric populations served. AIMS: Identify a de-escalation program, which is evidenced-based and able to be effective across all sizes and ages of patients served at this organization. METHOD: The work described in this article displays the thorough systematic process used to select a new behavioral health crisis prevention/de-escalation training program within a large children's hospital. RESULTS: Fourteen de-escalation programs were initially identified, nine of them were further analyzed based on curriculum, cost, training requirements, emphasis on verbal de-escalation, ability to address needs of those with Autism Spectrum Disorders, and overall fit for this organization. One final program was selected for implementation after a robust selection process. CONCLUSIONS: The team used a comprehensive approach during program selection to attempt to decrease or limit potential resistance to change from affected employees.

Violent incidents in a secure service for individuals with learning disabilities: Incident types, circumstances and staff responses

BACKGROUND

The issue of violence in secure services has long been recognized both in the UK and worldwide. However, there is currently scarce literature available about violence within learning disability (LD) secure settings.

METHODS

Secondary data analysis was conducted on violent incidents, using information routinely collected by the staff over a 1-year period.

RESULTS

Physical assaults were the most frequent type of incident, and the distribution in terms of days or months was homogenous and incidents were concentrated in the corridors, lounges and dining rooms of secure facilities. Antipsychotic medication was not regularly prescribed. Generalized linear modelling analyses revealed significant predictors that increased the chances of seclusion and physical restraint, such as being female or directing the violence towards staff.

CONCLUSIONS

These findings can inform staff training on violence prevention and suggest that increased ward-based supervision and enhanced use of psychological formulations may help in reducing violence within this service context.

Nurses' perceptions of personal attributes required when working with people with a learning disability and an offending background: a qualitative study

WHAT IS KNOWN ON THE SUBJECT?: Learning disability nursing in the area of people with a learning disability and an offending background has developed considerably over recent years, particularly since the publication of the Bradley (). There has been limited work into the competencies nurses require to work in this area, and even less about the personal attributes of learning disability nurses. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Learning disability nursing's specific contribution to the care of this population lies in their knowledge of the interaction between the learning disability, an individual's, sometimes abusive, personal history and an understanding of the subsequent offending behaviour. The knowledge base of nurses working with people with learning disabilities and an offending background needs to reflect the changing service user group. This is particularly in relation to substance misuse, borderline personality disorder, and mental health and the way such factors inter-relate with the learning disability. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Further research is required into the relationship among decision making, risk taking or reluctance to do this, and the personal attributes required by nurses to work in secure learning disability care. Learning disability secure services are likely to continue to undergo change as circumstances alter and the offending population demonstrate greater complexity; nursing competencies and personal attributes need similarly to adapt to such changes. Mental health nursing has a great deal to contribute to effective working with this population, specifically with regard to developing strong relationships when concerns around borderline personality disorder or substance misuse are particularly in evidence.

ABSTRACT

Aim To identify and discuss the personal attributes required by learning disability nurses to work effectively with people with an offending background in secure and community settings. Background This study was part of a larger research investigation into the nursing competencies required to work with people with an offending background. There are few existing studies examining the personal attributes necessary for working with this group. Design A qualitative study addressing the perceptions of nurses around the personal attributes required to work with people with learning disabilities and an offending background. Methods A semi-structured interview schedule was devised and constructed, and 39 individual interviews were subsequently undertaken with learning disability nurses working in high, medium, low secure and community settings. Data were collected over 1 year in 2010/11 and analysed using a structured thematic analysis supported by the software package MAXqda. Findings The thematic analysis produced three categories of personal attributes, named as looking deeper, achieving balance and connecting, each of which contained a further three sub-categories. Conclusion Nursing of those with a learning disability and an offending background continues to develop. The interplay among personal history, additional background factors, nurses' personal attributes and learning disability is critical for effective relationship building.