Analysis of violent incidents in a regional secure unit

A review of violent incidents in a multilevel secure forensic psychiatric hospital: is there a seasonal variation?

There have been several attempts made to reduce the occurrence of violence in hospital settings, with most professional organizations taking a stance. The impact of violent incidence on the therapeutic environment and the cost in human terms led to the declaration by the World Health Organization that violence is a public health problem. There are strategies for reducing violence that flow out of known trends. We sought to examine the trends in institutional violence in a contextual sense. We reviewed the records of all incidents of violence, categorized by severity, victims and trends over five years in a multilevel secure forensic hospital in Canada. The rate of violence perpetrated by female patients was significantly higher than for male patients. Higher occurrence of violence was recorded in the winter months compared with any other season and was related to unstructured activities. There is a window of opportunity to develop some engaging programmes during the long winter months and improve supervision at all times of unstructured activity. The reasons for increased women perpetration and the winter peak of violence require further investigation.

A review and meta-analysis of the patient factors associated with psychiatric in-patient aggression

OBJECTIVE

To combine the results of earlier comparison studies of in-patient aggression to quantitatively assess the strength of the association between patient factors and i) aggressive behaviour,ii) repetitive aggressive behaviour.

METHOD

A systematic review and meta-analysis of empirical articles and reports of comparison studies of aggression and non-aggression within adult psychiatric in-patient settings.

RESULTS

Factors that were significantly associated with in-patient aggression included being younger, male, involuntary admissions, not being married, a diagnosis of schizophrenia, a greater number of previous admissions, a history of violence, a history of self-destructive behaviour and a history of substance abuse. The only factors associated with repeated in-patient aggression were not being male, a history of violence and a history of substance abuse.

CONCLUSION

By comparing aggressive with non-aggressive patients, important differences between the two populations may be highlighted. These differences may help staff improve predictions of which patients might become aggressive and enable steps to be taken to reduce an aggressive incident occurring using actuarial judgements. However, the associations found between these actuarial factors and aggression were small. It is therefore important for staff to consider dynamic factors such as a patient's current state and the context to reduce in-patient aggression.

Manual restraint of adult psychiatric inpatients: a literature review

Relatively little is known about the prevalence of manual restraint to manage violent or challenging behaviour in hospital psychiatric services or the circumstances of its use. This review identified 45 empirical studies of manual restraint of adult psychiatric inpatients, mostly from the UK. On average, up to five episodes per month of manual restraint might be expected on an average 20-bed ward. Episodes last around 10 min, with about half involving the restraint of patients on the floor, usually in the prone position. Manually restrained patients tend to be younger, male and detained under mental health legislation. Staff value restraint-related training, but its impact on nursing practice has not been evaluated. Research has tended to focus on official reports of violent incidents rather than manual restraint per se. Larger and more complex studies are needed to examine how manual restraint is used in response to different types of incident and in different service settings.

Mental health nurses: de facto police

This paper examines the consequences for nursing staff and patients when police bring to hospital a person they assess to have a mental illness who exhibits violent or criminal behaviour. In particular, the impact on the nurse-patient relationship and the occupational health and safety of patients and staff is explored. Tensions between the conflicting roles for nurses of controlling the behaviour of this small minority of patients, while providing care and therapy, are examined within the context of health policy, bed shortages, and staffing problems. Recent Australian government and non-government reports are examined to assess the capacity of current health services in the State of New South Wales, to adequately and safely control behaviour while also provide therapeutic care for patients who are seeking help for their mental illness and emotional distress.

The conceptualization of physical restraint as a nursing-sensitive adverse outcome in acute care psychiatric treatment settings

The occurrence of physical restraint episodes in psychiatric settings is a major public health issue because the therapeutic utility of this form of behavior control has not been substantiated empirically. The purpose of this article was to examine the extant literature to determine if evidence supports the conceptualization of a physical restraint episode as an adverse client outcome that is sensitive to the organization of nursing care in psychiatric settings. An adapted version of the Quality Health Outcomes Model (Mitchell, P. H., Ferketich, S., & Jennings, B. M. (1998). Quality Health Outcomes Model. Image Journal of Nursing Scholarship, 30, 43-46) was used as the conceptual model to guide this inquiry. The databases Cumulative Index to Nursing and Allied Health Literature, Health and Psychosocial Instruments, HealthSTAR/Ovid and Healthstar, Medline, and psychINFO were searched from 1990 to 2005. There are 101 sources in this review. Evidence strongly suggests that a physical restraint episode is an adverse outcome that is sensitive to the organization of nursing care. A systematic exploration of the specific structures and processes of the organization that affect adverse outcomes, such as physical restraint episodes, is lacking in the United States.

Evaluating the validity of anger regulation problems, interpersonal style, and disturbed mental state for predicting inpatient violence

Research has been conducted to try to identify risk factors to help predict which patients will be violent during psychiatric hospitalization. Despite the relatively large amount of research conducted, it is difficult to draw any firm conclusions, as the studies vary considerably in study design, methods used, and choice of outcome measures. Studies also tend to focus on risk prediction, even though risk management is the primary aim of clinical practice in mental health services and few studies have focused on a theoretical basis for understanding violence. This study assessed the predictive validity of brief assessment scales in a sample of 94 forensic inpatients who had been inpatient for a median of 521 days, to test the hypotheses that anger regulation problems, interpersonal style, and disturbed mental state would be linked to increased violence risk in a forensic hospital during a hospital stay. The outcome variables for this study were physical violence against another and/or clear threats of physical violence. The results of this study provide support for the hypotheses, and this remained the case after controlling for age, gender, length of stay, and presence of major mental disorder. The findings should not only assist clinicians with assessment and management of risk but also support the reconceptualizing of risk prediction research to reflect the task of clinical risk management.

Repetitively assaultive psychiatric patients: review of published findings, 1978-2001

Embedded in samples of studies individual cases of psychiatric patient assault have been cases of persistent, repeat patient assailants. Although there have been literature reviews of samples of individual cases of assaults, there has been no similar review of the studies of repetitively violent patients. This paper reviewed 28 studies and found repetitively violent patients to be younger, equally male or female, and most frequently diagnosed with schizophrenia or personality disorder. The implications for safety, clinical care, and research are discussed. A new research approach is suggested.

Violence in treatment resistant psychotic inpatients

This study sought to: a) ascertain the effect on rates of violence by varying its operational definition and b) compare characteristics of violent and nonviolent patients. Aggressive behavior was recorded daily for every patient (N = 78) during a 2-year period. Standardized rating scales were used to rate psychopathology and functioning. Almost two thirds of patients were aggressive to others, and 26% violently assaulted another person. Official incident reports underestimated rates of violence to others, self- harm, and property damage. Multivariate predictive models that greatly improved accuracy over base rates showed that violent patients tended to be female, schizophrenic (nonparanoid type), and abusive of alcohol before admission. Violence is more common in treatment resistant psychotic inpatients than suggested by incident reports. Standardized definitions of violence are urged in order to accurately study its prevalence and correlates. Models combining both historical/demographic and clinical data may enhance prediction of violence.

A cost analysis of untoward incidents in a medium secure unit

All untoward incidents perpetrated by 36 patients--residents in a medium-secure hospital--over a period of six months were examined using a prospective design. Demographic and psychiatric details of patients involved in incidents were compared with those of patients not involved in incidents. Financial costs associated with incidents were calculated. A minority of patients were found to be responsible for the majority of incidents. Patients detained under criminal sections of the Mental Health Act 1983 were involved in disproportionately more incidents than their civil section counterparts. The female patients involved in untoward incidents all had a diagnosis of personality disorder and were over-represented in the number of incidents. However, most of the financial burden of untoward incidents was incurred by those incidents perpetrated by male patients. Likewise, although patients detained under the legal category of psychopathic disorder were involved in a higher number of incidents, higher costs were associated with incidents perpetrated by patients detained under the category of mental illness.

Crowding and violent behavior: the influence of patient density on violent and self-harming behaviour at a medium secure unit

This study examines the influence of patient density (crowding) and number of potential perpetrators on the number of incidents of violence and self-harm at a medium secure unit. Of 2,053 incidents examined over a period of 974 days, 73% were perpetrated by 20% of the patients, the majority by patients identified as potential perpetrators. Increased patient density was not associated with increased risk of violence or self-harm. There was no evidence to suggest that the presence of those identified as potentially violent or self-harming increased the risk of others engaging in such behaviour.