Handling conflict situations in psychosis inpatient care: Nursing staff experiences of the Interactive Approach model

WHAT IS KNOWN ON THE SUBJECT?: In inpatient wards, there is a risk that conflicts occur when nursing staff interact with psychotic patients. The Interactive Approach (IA) model is an action-based model, used in psychiatric settings, to manage conflict situations. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The IA model can be used to improve communication between nursing staff and patients in numerous critical situations. Using a structured risk scale to evaluate a conflict can be an effective way to guide action and sort out the different aspects of communication between nursing staff and psychotic patients. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The clarity of an action-based model will help sort out which interventions are most likely to succeed in each conflict situation. The IA model highlights the importance of understanding and strengthening the patient's perspective, being flexible for each individual patient, and providing the patient with clear information about the situation. ABSTRACT: Introduction The Interactive Approach (IA) model is a structured management tool used to improve communication between caregivers and patients in psychiatric care settings. Aim/Question To examine the nursing staff's experiences of the IA model. How do they use the interventions in conflict situations with psychotic patients? Method A sample of nursing staff (n = 11) was recruited from three psychosis inpatient care units. Semi-structured questions covered staff experiences of working with the problem-solving interventions in the IA model. Transcribed data were analysed by qualitative content analysis. Results Three categories were defined: (1) 'To apply a flexible approach' describes how staff tried to adapt to each patient and situation; (2) 'Try to understand the person's inner world' describes the importance of active listening and exploring the patient's concerns; and (3) 'To communicate clearly' relates to experiences of clear communication and the setting up of boundaries. Discussion The risk scale and training in communication skills helped the interaction between staff and patients in conflict situations. Different interventions were used with a focus on maintaining patient alliance. Implications for Practice The findings highlight the importance of educational efforts and practical training, to prevent violence and the use of coercive measures.

Psychological provision in acute inpatient settings: An evaluation of indirect input

WHAT IS KNOWN ON THE SUBJECT?: Psychiatric hospitals have input from a range of professionals, including Clinical Psychologists. Most evidence used to guide what Clinical Psychologists do is based on their work with individuals rather than staff teams. Some evidence shows working with staff teams is important, but most of this is based on interviews rather than measuring the impact using numbers and statistics. The current study aimed to investigate the effectiveness of staff-level interventions provided by a Psychology team within a psychiatric inpatient setting. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Training sessions were effective at increasing staff levels of confidence and understanding in psychological approaches, and the perceived usefulness of the session to their practice. Case discussion sessions were effective at increasing staff levels of understanding a service user, compassion towards the service user, perceived opportunities for change with the service user, their perceived skills to work with the service user and their perception of the usefulness of the session to their practice. Reflective practice sessions were effective at providing a space for learning, sharing ideas and reflecting. Other interventions were highly valued by nursing staff. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Staff-level interventions are effective and valued by mental health nursing staff and should be considered in allocation of psychology resources. Interventions improved staff psychological thinking which could positively impact service user experience. There is potential for people with lived experience to participate in these interventions, which could facilitate the therapeutic relationship and reduce restrictive practices.

ABSTRACT

INTRODUCTION: The role of Psychologists in psychiatric inpatient settings is well established and involves intervention at various levels; however, quantitative exploration of the effectiveness of staff-level interventions is lacking.

AIM

The aim of the study was to examine the effectiveness of a variety of staff-level interventions provided by a Psychology team within a psychiatric inpatient setting.

METHODS

The evaluation used a mixed methods approach incorporating pre-post quantitative data and post-intervention feedback. Additional data were collected via survey.

KEY FINDINGS

Results indicated all staff-level interventions were effective in achieving their aims and were highly valued by staff. Qualitative data supported the quantitative findings and showed tentative suggestion of a change to clinical practice.

DISCUSSION

Indirect psychology provision was found to significantly impact a range of staff attitudes and was highly valued by the staff team, supporting previous qualitative findings in psychiatric inpatient settings. Further quantitative evidence of the impact of staff-level interventions should be sought.

IMPLICATIONS

Staff-level interventions are effective and valued by mental health nursing staff and should be considered in allocation of psychology resources. Furthermore, there is potential for people with lived experience to participate in these interventions, which could facilitate the therapeutic relationship and reduce restrictive practices, however this requires future research.

["If certain tensions are present, it affects everyone": Multiple case study on processes of coercive measures.]

"If certain tensions are present, it affects everyone": Multiple case study on processes of coercive measures. Abstract: Background: There is an urgent need to reduce coercive measures in psychiatric care. The interaction between patients, nursing staff and medical professionals influences the course of a coercive measure. Aim: The interaction before, during and after coercive measures will be described and compared from the perspectives of the parties involved in order to identify a potential for prevention and quality improvement. Methods: A multiple case study of three coercive measures was conducted, each consisting of interviews with three participants, case documentation, photos, and observation. The data material was analysed thematically with subsequent single-case and cross-case analysis. Results: The thematic analysis revealed three areas of tension: tension and relaxation, humaneness and dehumanisation, as well as safety and autonomy. The stage before coercion was characterised by interacting tensions and the influence of emotions and stress. In all cases, a verbal communication gap was present. During the coercive measure, the quality of interactions between patients and nurses determined their experience. After coercion, the impacts of the measure on the persons and their relationships as well as reflections were the focus. Conclusions: De-escalation techniques turn out to be a key issue, whereby special attention should be paid to emotional and nonverbal aspects in the future. The results underline the relevance of empathy and respect throughout the process for prevention as well as for quality of care. Debriefings of coercive measures should be conducted routinely.

Aggressive Incidents by Incarcerated People With Psychiatric Illness and Their Relationship With Psychiatric Symptoms

AIM

A prospective design was used to investigate the relationship of current psychiatric symptoms of incarcerated people with serious mental illness (SMI) and aggressive behavior on a penitentiary ward for crisis intervention.

METHODS

One hundred sixty detainees with SMI, detained in a high-security penitentiary psychiatric facility, were screened every 2 weeks with the Brief Psychiatric Rating Scale-Extended (BPRS-E) by trained clinicians, to ensure that the data on psychiatric symptoms were up-to-date. Aggressive behavior was registered with the Staff Observation Aggression Scale-Revised. A binary logistic regression analysis was performed to examine the relationships between factor scores of the BPRS-E and aggressive behavior.

RESULTS

Significant relationships between the BPRS-E factor hostility, antisocial traits, and aggressive incidents were found, but not between the positive symptoms or manic factor scores and aggressive incidents.

DISCUSSION

Symptoms of SMI measured with the BPRS-E did not help to explain the occurrence of aggressive behavior. This is not in line with what is commonly found. The implication is that it can be expected that this population will display aggressive behavior but that symptoms do not help in predicting when this will occur. In addition, hostility and antisocial traits were related to aggressive behavior. For this specific population, an interactional approach might be more effective in the management of aggression than treatment of symptoms of SMI.

Newtonian science, complexity science and suicide-critically analysing the philosophical basis for suicide research: A discussion paper

AIM

A critical discussion comparing Newtonian science and complexity science as the philosophical basis for suicide research and its impact on suicide knowledge development and clinical practice.

DESIGN

Discussion paper.

DATA SOURCES

A review of literature on suicide research and complexity science ranging from 2000 to 2022.

IMPLICATIONS FOR NURSING

Suicide research based on a Newtonian worldview can have negative consequences for suicide knowledge development and can permeate nursing practice in ways that take away from addressing the complex needs of patients, their families and healthcare teams.

CONCLUSION

A Newtonian worldview as a philosophical basis for research is insufficient for the study of a phenomenon as complex as suicide. A complexity science approach is better suited to the study of suicide given the multiple, interrelated, emerging factors that can contribute to a person's decision to end their own life.

IMPACT

Suggestions are provided as to how a complexity science approach to the research of suicide can inform useful knowledge development that better meets the needs of individuals facing suicidality and their families. Researchers, healthcare administrators and nurses providing care to those struggling with suicidality can benefit from adopting a complexity science worldview in addressing this multifaceted phenomenon.

Prevalence and severity of verbal, physical, and sexual inpatient violence against nurses in Swiss psychiatric hospitals and associated nurse-related characteristics: Cross-sectional multicentre study

This analysis (1) describes the prevalence and severity of psychiatric inpatient violence against nurses in Switzerland's German-speaking region and (2) investigates the associations between nurse-related characteristics (socio-demographics; previous exposure to severe forms of psychiatric inpatient violence; attitude towards psychiatric inpatient violence) and nurses' exposure to various types of psychiatric inpatient violence. We used cross-sectional survey data from the Match^RN Psychiatry study sample of 1128 nurses working on 115 units across 13 psychiatric hospitals. In addition to lifetime severe assaults, nurses' exposure to violence against property, verbal violence, verbal sexual violence, physical violence, and physical sexual violence was assessed for the 30 days prior to the survey. Descriptive statistics (frequency and percentage) were calculated for each class of violence as also for items under study. With generalized linear mixed models, odds ratios and 95% confidence intervals were calculated. Of nurse respondents, 73% reported facing verbal violence, 63% violence against property, 40% verbal sexual violence, 28% physical violence, and 14% physical sexual violence. Almost 30% had been subjected to a serious assault in their professional lifetimes. All nurse characteristics were associated with psychiatric inpatient violence against nurses, especially a history of sexual assault (OR 4.53, 95%-CI 2.19-9.34; P = 0.00) and ≤3 years' professional experience (OR 3.70, 95%-CI 1.95-7.02; P = 0.00). Prevalence data suggest that widely used strategies such as aggression management courses or alarm devices cannot fully reduce patient violence against nurses in psychiatry. This situation demands proactive strategies in safety and violence prevention.

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.

Comparison of patients' and staff's perspectives on the causes of violence and aggression in psychiatric inpatient settings: An integrative review

WHAT IS KNOWN ON THE SUBJECT?: Aggression and violence are persistent problems in psychiatric inpatient units. Violence preventive factors have been identified from both staff's and patients' perspectives. Violent and aggressive inpatient incidents have not been adequately explained in research and reviews to date. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This review is novel in that it provides a comparison of patients' and staff's perspectives and identified that these differ and were influenced by factors attributable to the inpatient culture. The one contributory factor both agreed upon was the role of staff's interpersonal skills in either exacerbating or de-escalating aggression and violence. The inpatient culture was found to engender differing perceptions of most contributory factors to violence and aggression. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: While staff's interpersonal skills were identified as a primary influence on whether their interaction with patients contributed to aggression and violence, this was shaped by the inpatient environment's culture. Patient-centred interactional skills need to focus on the patients' needs for respect and active participation rather than engendering feelings of disrespect or coercion. Patient-centred communication skills that demonstrate an understanding of the patient's experience in the inpatient environment need to be core skills for mental health nurses. ABSTRACT: Introduction High rates of aggression and violence are a persistent problem in inpatient mental health environments. A comparison of staff's and patients' perceptions of the causes may provide novel insights. Aim This review aimed to compare patients' and staff's perspectives on the causes of aggression and violence in inpatient environments. Method An integrative review of the literature was conducted with a search of Ovid (Medline, Embase, PsycINFO) databases and manual searching. Results Thirty articles met criteria for inclusion. Interactions prior to aggressive or violent incidents were characterized by patients as disrespectful and coercive, and by staff as indicative of the patient's mental state or personality. Both groups identified the importance of patient-centred communication skills. Discussion The review identified that patients and staff have differing perspectives on the causes of violence and aggression. There was an interactional dynamic between staff and patients that was shaped by the culture of the inpatient setting. Implications for Practice Understanding how the inpatient culture plays a role in shaping a dynamic between patients and staff and developing communication skills that acknowledge this may help reduce violence and aggression in inpatient settings.

How does the environment influence consumers' perceptions of safety in acute mental health units? A qualitative study

AIMS AND OBJECTIVES

To explore how the physical and social environment of acute mental health units influences consumers' perception and experience of safety.

BACKGROUND

Acute mental health units are places in which consumers should feel safe. Not all consumers, however, feel safe in this environment. Little is known about what contributes to consumers' feelings of safety in this setting.

DESIGN

The study used a qualitative descriptive design, influenced by naturalistic enquiry. Data were analysed using thematic analysis and are reported according to the COREQ checklist.

METHODS

Fifteen people who had experienced admission to an acute mental health unit were individually interviewed.

RESULTS

Having a supportive environment enhanced consumers' perception and experience of safety. A supportive environment was experienced when consumers had privacy, felt safe from other consumers and had meaningful activities to participate in within the acute mental health unit. In contrast, having their privacy breached by other consumers made participants feel unsafe. Many participants were fearful of other consumers, and felt unsafe and unable to protect themselves. Lack of meaningful activities led to boredom and contributed to consumers feeling unsafe.

CONCLUSIONS

Personal spaces should address consumers' privacy needs without compromising staff access. Staff presence enhances consumers' feelings of safety, but this need can be heightened when consumers are unable to alert staff when they feel unsafe. Meaningful activities link consumers to their lives outside of the hospital and can enhance recovery.

RELEVANCE TO CLINICAL PRACTICE

Understanding how the acute unit environment is perceived by consumers can assist nurses and managers to promote feelings of safety among consumers. Feeling safe can, in turn, optimise recovery.

Reducing aggression in psychiatric wards using Safewards-A Polish study

PURPOSE

To reduce the use of mechanical restraints, Safewards was introduced to a ward in a psychiatric hospital in Poland.

DESIGN AND METHODS

Three aspects of Safewards were applied for 8 months. The comparison time period was the same time frame of the previous year.

FINDINGS

Restraint use dropped by 24%, and the number of patients restrained dropped 34%. The duration of restraint remained at 2.8 days per episode.

PRACTICE IMPLICATIONS

Simple techniques aimed at promoting positive interactions between staff and patients can reduce the frequency of restraints.

Patient and visitor aggression in healthcare: A survey exploring organisational safety culture and team efficacy

AIMS

This study investigates nurse managers' perception of organisational safety culture and team efficacy in managing patient and visitor aggression , and determines the predictors of team efficacy.

BACKGROUND

Patient and visitor aggression is a serious hazard in healthcare. A positive organisational safety culture regarding patient and visitor aggression enhances the safety and staff efficacy in managing patient and visitor aggression.

METHODS

A cross-sectional online survey including nurse managers in psychiatric and general hospitals (n = 446) was conducted in Switzerland, Austria and Germany (November 2016-February 2017). Data were analysed descriptively and through binary logistic regression.

RESULTS

The key results are as follows: "Working in a mental health setting" was 3.5 times more likely, "consideration of the physical environment" was four times more likely and a "shared organisational attitude" was twice as likely to predict high team efficacy. In comparison to psychiatric hospitals, general hospital managers perceived organisational safety cultures to be less positive.

CONCLUSIONS

A positive organisational safety culture leads to the perception that teams are more effective at managing patient and visitor aggression.

IMPLICATIONS FOR NURSING MANAGEMENT

Consideration of the physical environment and a positive shared organisational attitude regarding patient and visitor aggression are crucial for high team efficacy. General hospitals could benefit from approaches utilized in psychiatry to enhance staff efficacy in managing patient and visitor aggression.