Violent incidents in a psychiatric intensive care unit

Characteristics and outcomes of patients admitted to the first psychiatric intensive care unit in Egypt

Background

Psychiatric intensive care units (PICU) have become an essential part of psychiatric hospital design worldwide, there are few published data about their effectiveness.

Aim

In this study, the characteristics and outcomes of 50 Egyptian patients admitted to the first PICU in the Middle East region between April 2015 and October 2018 were retrospectively examined.

Setting

The study was conducted at the Institute of Psychiatry, Ain Shams University.

Methods

Data on patients in PICU at the Institute of Psychiatry, Ain Shams University, were collected retrospectively and analysed and included information on previous psychiatric contact, diagnoses, causes of admission and outcomes. Continuous and categorical variables were subjected to statistical analyses.

Results

The majority of patients in PICU were of female gender, having a diagnosis of schizophrenia. The most common reason for admission to the PICU is the management of delirium, followed by catatonia. The average length of patients’ stays in PICU ranged from half a day to 16 days. Immediate outcome differed where the majority of patients (47 patients, 94%) were discharged to the inpatient psychiatric ward.

Conclusion

This study reviewed practice in the first PICU in Cairo, Egypt, over 3 years, showing the importance of ongoing evaluations of patient populations in providing the best clinical practice; the typical PICU patient is likely to be: female, suffering from schizophrenia or bipolar affective disorder (BAD). The most common reason for PICU admission is for the management of delirium followed by catatonia.

Assessing risk of interpersonal violence in the mentally ill

Mental health professionals regard the assessment of suicide risk as part of normal clinical practice, but most shy away from assessment of risk of interpersonal violence, either doubting that such predictions are possible, or, if possible, are part of their role. In part, this fastidiousness reflects the influence of a consensus which emerged in the 1970s to the effect that there was no substantial relationship between mental illness and violent behaviour. The only basis for risk assessments which remained were those factors in the general population known to be associated with criminality. Even here, however, the accuracy of predictions made by clinicians had been subject to considerable critical scrutiny, which undermined any claims the profession may have had to expertise (Monahan, 1981; Brizer, 1989). There seems to have been wide acceptance that psychiatrists were doubly disabled in the business of predicting violence by having no relevant specialist knowledge and by being poor at applying knowledge gleaned from other disciplines such as criminology.

Monitoring inner London mental illness services

Our objective was to establish a mechanism for monitoring indicators of the state of health of inner London's mental illness services. Data were collected for a census week around 15 June 1994. Local data collection was coordinated by consultant pyschiatrists working in inner London services. Twelve services participated with a combined catchment population of 2.6 m. They included ten London services which were among the 17 most socially deprived areas of England. Main indicators were admission bed occupancy levels (including an estimate of the total requirement), proportion of patients detained under the Mental Health Act, number of assaults committed by inpatients, number of emergency assessments and CPN caseloads. The mean true bed occupancy (which reflects the number of patients who were receiving, or required, in-patient care on census day) was 130%. To meet all need for acute psychiatric care, including for patients who should have been admitted and those discharged prematurely because beds were full, a further 426 beds would have been required. Fifty per cent of patients were legally detained. Physical assaults were virtually a daily occurrence on the admission units. Average community pyschiatric nurse caseloads were 37, suggesting that the majority were not working intensively with limited caseloads of patients with severe mental illness. These indicators, although imperfect, will allow for some measurement of the impact of local and central initiatives on the poor state of London's mental illness services.

Management of violence among psychiatric in-patients

In a retrospective study at a medium secure unit, the incident reports where a degree of restraint was used in dealing with in-patient aggression were examined for management strategies used and their relationship to various factors. There was a decrease in the use of seclusion over the period of study, seclusion being more likely to be used when agression was aimed at staff and property, following staff-patient interaction (demands) and younger age of perpetrators.

Prosecution of physical assaults by psychiatric in-patients in Northern Ireland

Aims and Method

Assaults in healthcare settings have resulted in a range of national strategies aimed at reducing the incidence of violence. This study aimed to quantify the use of prosecution of assailants as a response, and to examine what other responses were used. the responses to violent incidents in three Northern Ireland psychiatric in-patient units in the year 2003 were ascertained retrospectively.

Results

Of 245 incidents meeting the legal definition of assault, police were contacted in 10, and 1 resulted in a prosecution. Seven in-patients accounted for 30.4% of assaults. of the assaults, 46.5% were dealt with by staff using de-escalation alone.

Clinical Implications

These results demonstrate the infrequent reporting of such assaults to the police. A more structured approach should be taken to this important decision. Factors relating to the prosecution of assaults in psychiatric in-patient units are discussed.

Social deprivation, ethnicity and violent incidents on acute psychiatric wards

A retrospective comparative study of violent incident forms covering the acute general adult wards at a London teaching hospital and a district general hospital was performed. Although no significant difference was observed between the overall rates of reported violent incidents, there was a significant increase in the proportion of violent incidents directed at persons in the inner city hospital. Grade 3 incidents were rare. Caribbean patients were over-represented among the perpetrators.

Resource consumption in psychiatric intensive care: The cost of aggression

The coils of operating a psychiatric intensive care unit (PICU) were recorded for a six-month period. There were 110 admissions and 99 discharges. Mean length of stay was 12.3 days. Total costs were £346,516 over the study period, £283.56 per patient-day. Fixed costs comprised 93% of the total, inducing nursing staff ($169,447), overheads ($77,017), medical staff ($48,819), hotel costs (£24,160) and miscellaneous (£1,750). Variable costs included special nursing, (£19,405), treatment of major self-harm (£3,024), drugs (£1,707) and staff time to manage aggressive incidents (£1,188). Reduction of the incidence of aggression could result in valuable cost savings.

Management of psychiatric in-patient violence in the Anglia region

Aims and method

A total of 384 incidents of violence against the person (six ‘serious' and 378 ‘mild’), by adult in-patients in general psychiatric units (GPUs) and learning disability units (LDUs) in 10 National Health Service trusts in the Anglia region, were evaluated by Interviews with staff and examination of records.

Results

The findings, when compared with standards derived from previous recommendations, showed deficiencies in the documentation of incidents (there was no satisfactory written record of physical restraint for 97% of incidents in GPUs and 86% in LDUs), in the training of staff in ‘control and restraint’ procedures (If two or more staff were involved In physical restraint, for 3% of incidents in GPUs and 100% in LDUs, the staff had received no training within the previous 12 months) and in policies for victim support (there was no written policy that included procedures for victim support in relation to 84% of incidents in GPUs and 44% in LDUs).

Clinical implications

Trusts should consider reviewing their policies on the prevention and management of violence, particularly in relation to staff training.

Characteristics of Patients Involved in Physical Assault in an Acute Inpatient Psychiatric Setting

BACKGROUND

Although aggressive behavior in psychiatric settings is a major concern, very few studies have focused exclusively on physical assault in a general inpatient psychiatric population.

OBJECTIVES

This study had 3 main goals: (1) to evaluate the prevalence of assaultive behavior in an acute psychiatric hospital; (2) to identify the clinical and socio-demographic factors associated with assaultive behavior during hospitalization; and (3) to explore whether a diagnosis of schizophrenia spectrum disorder increases the risk of assaultive behavior.

METHODS

We conducted a retrospective chart review of patients admitted to acute units in a psychiatric hospital between 2009 and 2012. A subset of occurrence reports identified by a multidisciplinary team as "physical assault" was included in the analysis. Using logistic multivariate regression analysis, these patients were compared with a randomly selected nonassaultive control group, matched for length of stay to identify factors associated with assaultive behavior.

RESULTS

Of 757 occurrence reports, 613 met criteria for significant assault committed by 356 patients over 309,552 patient days. The assault incident density was 1.98 per 1000 patient days. In the logistic regression model of best fit, the factors significantly associated with assaultive behavior were age, legal status, and substance use. A diagnosis of schizophrenia spectrum disorder was not significantly associated with assaultive behavior.

CONCLUSIONS

Clinicians should take extra precautions for involuntarily admitted young patients with a history of substance use, as they are more likely to exhibit assaultive behavior. A diagnosis of schizophrenia spectrum disorder in itself is not significantly associated with assaultive behavior. Screening instruments such as the Dynamic Appraisal of Situational Aggression may be useful in assessing risk of assault.

An audit of violent incidents in a drug treatment centre

Objectives: The aim of this study was to examine the prevalence of, and factors associated with violence in a drug treatment centre.

Method: This study is a retrospective audit of all incident forms completed at an urban drug treatment centre between December 1991 and July 1996 with reference to case notes for additional clinical information on individuals involved in violent incidents.

Participants included all patients attending the centre in the aforementioned time period who were involved in violent incidents. Information was obtained about the prevalence and severity of violent incidents and patient details including main drug of abuse, route of use, reason for attendance, comorbid axis 1 diagnosis, history of previous incidents and HIV status at the time of the incident.

Results: One per cent of all patients were involved in violent incidents. Less than one quarter of incidents involved serious injury or assault. Most perpetrators were male intravenous heroin users on a methadone maintenance programme. Nurses and doctors were most frequently the victims of incidents. Ten per cent of patients had a history of previous incidents and almost half the perpetrators were HIV positive. A comorbid axis 1 diagnosis was found in 9% of perpetrators (n = 6), mainly alcohol dependence syndrome.

Violence and aggression in the Drug Treatment Centre Board

Objectives: We sought to determine the prevalence of and the factors associated with violent and aggressive incidents among clients attending an out-patient methadone stabilisation and detoxification programme in Dublin.

Methods: We retrospectively examined all incident report forms over a two-year period. We also obtained information on demographics, main drug of abuse, timing and location of the incident as well as psychiatric and physical comorbidity among the perpetrators from case note review.

Results: Two hundred and ninety-five incidents occurred over the study period. The overall rate of violence and aggression was 85 per 1,000 clients attending the centre per year. Most incidents involved verbal abuse. Females were significantly more likely to be involved in assaults compared to males. A high proportion of clients (80%) who were physically aggressive tested positive for benzodiazepine medication.

Conclusions: Levels of recorded violence have remained stable however racial abuse has increased in recent years. The relatively low overall rate of violence suggests that existing measures have helped reduce the number of aggressive and violent incidents in the centre. Most of the victims were either doctors, nursing staff or general assistants. This finding reflected their respective roles in the centre, which included limit setting and dealing with positive drug screens among clients.

Systemic perspective of violence and aggression in mental health care: towards a more comprehensive understanding and conceptualization: part 2

This is the second of a two part paper which seeks to explore a wide range of phenomena that have been found to have an association with aggression and violence (A/V) in inpatient mental health care, synthesize these propositions according to fit or congruence into a systemic model of A/V, explore the empirical evidence pertaining to these propositions, and begin to consider application of this model to better inform our individual and/or organizational responses to A/V in mental health care. The systemic model is comprised of four thematic categories with part two of the paper focusing on the final two categories: mental health-care system-related phenomena and clinician-related phenomena. The paper then discusses a number of implications arising out of embracing a more systemic model of A/V in mental health care. In broadening our understanding to include all the phenomena that contribute increased risk of A/V incidents, we are able to move away from inaccurate views that disproportionately assign 'responsibility' to clients for causing A/V when the evidence indicates that the client-related phenomena may only account for a small portion of these incidents.

Modification of severe violent and aggressive behavior among psychiatric inpatients through the use of a short-term token economy

PURPOSE

Meager research has been carried out to determine the effectiveness of the token economy among patients behaving violently in mental hospitals. The purpose of this study was to examine the effectiveness of the Short-Term Token Economy (STTE) on violent behavior among chronic psychiatric in-patients.

METHODS

A nonequivalent control group design method was utilized. Participants in an experimental group (n=22) and control group (n=22) took part in this study from January to April, 2008. Observation on aggressive behavior among male in-patients in one hospital as a baseline was made during the week before the behavior modification program and measurement of aggressive behavior was done using the Overt Aggression Scale (OAS), which includes verbal attacks, property damage and physical attacks.

RESULTS

The aggressive behavior scores of the experimental group decreased, those of the control group, scores showed an increase after the eight-week behavior modification program utilizing STTE.

CONCLUSION

The results of the study indicate that STTE is effective in reducing the incidence of aggressive behavior among male in-patients in psychiatric hospitals. The outcome of this study should be helpful in reducing the use of coercive measures or psychoactive medication in controlling the violent behavior among in-patients in hospitals.

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.

The antecedents of violence and aggression within psychiatric in-patient settings

OBJECTIVE

To systematically review the types and proportions of antecedents of violence and aggression within psychiatric in-patient settings.

METHOD

Empirical articles and reports with primary data pertaining to violence and aggression within adult psychiatric in-patient settings were retrieved. For each study, prospective antecedent data were extracted. The extracted antecedent data were thematically analysed, and all higher-level themes were meta-analysed using rate data.

RESULTS

Seventy-one studies met the inclusion criteria, from which 59 distinct antecedent themes were identified and organised into nine higher-level themes. The higher-level antecedent theme 'staff-patient interaction' was the most frequent type of antecedent overall, precipitating an estimated 39% of all violent/aggressive incidents. An examination of the staff-patient interaction themes revealed that limiting patients freedoms, by either placing some sort of restriction or denying a patient request, was the most frequent precursor of incidents, accounting for an estimated 25% of all antecedents. The higher-level themes 'patient behavioural cues' and 'no clear cause' also produced other large estimates and were attributed to 38% and 33% of incidents overall.

CONCLUSION

This review underscores the influence that staff have in making in-patient psychiatric wards safe and efficacious environments.

'Living in an alternative reality': adolescents' experiences of psychiatric inpatient care

BACKGROUND

  To date minimal research has investigated adolescent psychiatric inpatient care from a service-user perspective.

METHOD

  Semi-structured interviews were conducted with 10 adolescents with experience of psychiatric inpatient care. Interviews were analysed using the grounded theory method (Glaser & Strauss, 1967).

RESULTS

  A core category, 'Living in an Alternative Reality', reflected the unusual nature of the hospitalisation experience. Adolescents reported feelings of restriction and disconnection and used various relational and practical strategies to cope with hospitalisation.

CONCLUSIONS

  Results suggest that psychiatric hospitalisation can cause strong affective reactions in adolescents, and may affect psychological constructs such as identity and self-esteem.

Short-term prediction of threatening and violent behaviour in an Acute Psychiatric Intensive Care Unit based on patient and environment characteristics

BACKGROUND

The aims of the present study were to investigate clinically relevant patient and environment-related predictive factors for threats and violent incidents the first three days in a PICU population based on evaluations done at admittance.

METHODS

In 2000 and 2001 all 118 consecutive patients were assessed at admittance to a Psychiatric Intensive Care Unit (PICU). Patient-related conditions as actuarial data from present admission, global clinical evaluations by physician at admittance and clinical nurses first day, a single rating with an observer rated scale scoring behaviours that predict short-term violence in psychiatric inpatients (The Brøset Violence Checklist (BVC)) at admittance, and environment-related conditions as use of segregation or not were related to the outcome measure Staff Observation Aggression Scale-Revised (SOAS-R). A multiple logistic regression analysis with SOAS-R as outcome variable was performed.

RESULTS

The global clinical evaluations and the BVC were effective and more suitable than actuarial data in predicting short-term aggression. The use of segregation reduced the number of SOAS-R incidents.

CONCLUSIONS

In a naturalistic group of patients in a PICU segregation of patients lowers the number of aggressive and threatening incidents. Prediction should be based on clinical global judgment, and instruments designed to predict short-term aggression in psychiatric inpatients.

TRIAL REGISTRATIONS

NCT00184119/NCT00184132.

The shoulder: taking the strain during restraint

The decision to use or utilize physical intervention techniques is a contentious one. There has been much discussion on the complex legal and ethical dimensions framing the use of force. The risk of injury has also been considered in detail, but almost all of the published work has focused on restraint asphyxia, the prone restraint hold and the use of particular pain compliance techniques such as the wrist flexion hold. This paper focuses on the structure and function of the shoulder and examines how physical interventions and a variety of risk factors can threaten its physical integrity. This paper is for practitioners such as training commissioners, trainers, frontline staff and investigators or regulators who have to make considered determinations on the potential immediate physical impact of a variety of holds and escape manoeuvres. Sound risk assessment must be premised on a sound understanding of anatomy and physiology.

A psychiatric intensive care unit for older adults: an interval comparison of admissions

BACKGROUND

Published information on psychiatric intensive care provision and requirements of older adults is limited. This audit aims to describe and compare demographic data, clinical characteristics and outcomes of patients admitted to a Scottish regional psychiatric intensive care unit (PICU) for older adults during two 18-month periods five years apart.

METHOD

Data on all patients admitted to the PICU for older adults during the two sample periods, commencing 2001 and 2006 respectively, were collected prospectively by the clinical care team, and included information on previous psychiatric contact and detentions under mental health legislation, diagnoses, cognitive ratings, reasons for transfer to the PICU, treatments and outcomes. Continuous variables were subject to statistical analyses.

RESULTS

Twenty-one and 20 male patients were admitted during the 2001 and 2006 cohorts respectively, with equivalent mean ages of 72.9 years. The majority of patients were married, diagnosed with dementia, with similar levels of previous psychiatric admissions and detentions under mental health legislation. The commonest reason for transfer to the PICU was physical aggression. The 2006 cohort exhibited shorter inpatient stays prior to transfer to, and shorter durations of stay in, the PICU.

CONCLUSIONS

The PICU for older adults provides a function similar to the PICU for general adults. The cohorts were similar on most recorded variables, with noted differences possibly reflecting increased awareness and acceptance of the service, reduced tolerance by staff of aggressive behaviors by patients, and enhanced community services in the region. These perceptions warrant further study and clarification.

[Patient-oriented management of aggression and violence in psychiatry. Description of a training program and first results]

Violence, aggression, and patient assaults result in a considerable number of job-related accidents in psychiatry. We describe a patient-oriented training program for managing aggression and violence in psychiatry. Ratings by 335 training participants indicate high to very high acceptance. In addition, ratings in the questionnaire for the study subjects' beliefs about competence and control suggest a statistically significant increase in active behavior and internal locus of control in 31 subjects. No significant changes were observed in the waiting-list control group. Our results suggest that a patient-oriented training program for the management of aggression and violence in psychiatry can have high acceptance and lead to lasting changes in beliefs about competence and control, resulting in an increased internal locus of control.

Adverse incidents in acute psychiatric inpatient units: rates, correlates and pressures

OBJECTIVE

This paper reports findings from a multicentre service evaluation project conducted in acute psychiatric inpatient units in NSW, Australia. Overall rates of aggression, absconding and early readmission are reported, as well as length-of-stay profiles and associations between these outcomes and selected sociodemographic and clinical characteristics routinely collected by health services.

METHOD

Data from the 11 participating units were collected for a 12month period from multiple sources, including electronic medical records, routine clinical modules, incident forms, and shift based project-specific logs. For the current analyses, two admission-level datasets were used, comprising aggregated patient-level events (n=3242 admissions) and basic sociodemographic, clinical, admission and discharge information (n=5546 admissions by 3877 patients).

RESULTS

The participating units were under considerable strain: 23.3% of admissions were high acuity; 60.4% had previous hospital stays; 47.6% were involuntary; 25-30% involved adverse incidents; bed occupancy averaged 88.4%; median length of stay was 8 days (mean=14.59 days); and 17.4% had a subsequent early readmission. Reportable aggressive incidents (11.2% of admissions) were intermittent (averaging 0.55 incidents per month per occupied bed) and associated with younger age, personality disorder, less serious aggression, longer periods of hospitalization, and subsequent early readmission. Less serious aggressive incidents (15.0% of admissions) were maximal in the first 24h (averaging 3.73 incidents per month per occupied bed) and associated with younger age, involuntary status, bipolar and personality disorders, the absence of depression, and longer hospital stays. Absconding (15.7% of admissions) peaked in the second week following admission and was associated with drug and alcohol disorder, younger age, and longer periods of hospitalization.

CONCLUSIONS

By examining relationships between a core set of risk factors and multiple short-term outcomes, we were able to identify several important patterns, which were suggestive of the need for a multi-level approach to intervention, shifting from a risk management focus during the early phase of hospitalization to a more targeted, therapeutic approach during the later phase. But the latter approach may not be achievable under current circumstances with existing resources.

Psychiatric intensive care units: a literature review

BACKGROUND

Psychiatric Intensive Care Units (PICU) have been part of most inpatient psychiatric services for some time, although information about their functioning and outcome has not previously been collated.

AIM

To conduct a systematic literature review to assess the current state of knowledge about such services.

METHOD

A search of electronic databases was undertaken, followed by obtaining additional references from items obtained.

RESULTS

Over 50 papers in English containing some empirical data were identified. Most studies were retrospective. Typical PICU patients are male, younger, single, unemployed, suffering from schizophrenia or mania, from a Black Caribbean or African background, legally detained, with a forensic history. The most common reason for admission is for aggression management, and most patients stay a week or less. Evidence of the efficacy of PICU care is very poor.

CONCLUSIONS

Most research so far has been small scale, and more substantial work using better methodologies is clearly required.

Junior staffing changes and the temporal ecology of adverse incidents in acute psychiatric wards

AIM

This paper reports an examination of the relationship between adverse incident rates, the arrival of new junior staff on wards, and days of the week on acute psychiatric wards.

BACKGROUND

Incidents of violence, absconding and self-harm in acute inpatient services pose risks to patients and staff. Previous research suggests that the arrival of inexperienced new staff may trigger more adverse incidents. Findings on the relationship between incidents and the weekly routine are inconsistent.

METHOD

A retrospective analysis was conducted of formally reported incident rates, records of nursing student allocations and junior doctor rotation patterns, using Poisson Regression. Variance between days of the week was explored using contingency table analysis. The data covered 30 months on 17 psychiatric wards, and were collected in 2002-2004.

FINDINGS

The arrival of new and inexperienced staff on the wards was not associated with increases in adverse incident rates. Most types of incidents were less frequent at weekends and midweek. Incident rates were unchanged on ward-round days, but increased rates were found on the days before and after ward rounds.

CONCLUSION

Increased patient tension is associated with raised incident rates. It may be possible to reduce incident rates by moderating stimulation in the environment and by mobilizing support for patients during critical periods.

An analysis of nurses' post-incident manual restraint reports

Manual restraint techniques are associated with the management of violence in psychiatric settings. Restraint effectiveness and acceptability are under scrutiny, yet the nature and frequency of who or what were involved in restraint episodes have not previously been fully described or understood. The aim of this study was to describe the nature and frequency of manual restraint-related events and their components. This study was carried out using content analyses of nurses' post-incident reports from a psychiatric unit situated within a general hospital, and from its associated medium-secure unit. Requests for restraint occurred at the rate of about once per day, and the majority related to patients' ill-directed frustration, resistance to containment and their desire to leave the ward. Only half of responses to conflicts resulted in restraint implementation. The majority of restraint activities occurred during the afternoon and night. Male patients and detained patients were more frequent participants in restraint interventions. To a lesser extent, police, ambulance, fire services, hospital security, visitors and ex-patients were also involved in restraint episodes. Injuries were rare. In conclusion, training in restraint skills, clinical audit of adverse incidents, and research into psychiatric aggression all need to take into account the association of restraint with the enforcement of detention and treatment of acutely ill patients. The coupling of restraint with medication requires examination of its safety and efficacy. Interagency training may enable the essential services involved to coordinate restraint activities more effectively.

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.

Is the reducing effect of the Staff Observation Aggression Scale owing to a learning effect? An explorative study

Is the reducing effect of the Staff Observation Aggression Scale owing to a learning effect? An explorative study Abstract This study explores the decline in the amount of reported aggression incidents when using the Staff Observation Aggression Scale (SOAS). Because this decline could hold significant implications for practice or research, the objective of this study was to explore the plausible explanations for this phenomenon. The influence of systematic feedback of the gained data was also studied. The SOAS was introduced on a closed ward in a psychiatric institution in the Netherlands as a measuring instrument to assess the amount of aggression incidents during a 16-week period. The standard procedure for reporting general incidents was continued. After 10 weeks of registration, systematic feedback of the gathered data took place. Statistic analysis was used to determine significant changes in the total amount as well as on the various forms of aggression. During this observation period, qualitative data were collected to support the analysis of the quantitative data. A significant decrease in the total amount of reported aggression incidents as well as in the categories of 'verbal aggression' and 'remaining aggression' was found. However, the category 'physical aggression' was stable during the entire observation period. The number of standard procedure reports did not decrease when compared with the pre-test period. Nursing staff did not recognize a reduction in the amount of aggression incidents. The role of a learning effect in the reduction of reports on aggression incidents is not excluded but there are indications that the reduction is also the result of 'reporting fatigue' and 'shifting attention'.

Prediction of inpatient violence

OBJECTIVE

An overview of studies on predictors and on the accuracy of prediction of inpatient violence should be given.

METHOD

To date, the published data do not allow a systematic meta-analysis due to different sample characteristics, different measures and definitions of violence, and different time frames of observation. Published studies were reviewed regarding significant predictors of inpatient violence.

RESULTS

Predictors of violence in institutional settings are different from predictors of violence in the community: variables such as sex, age, diagnosis and alcohol abuse play a minor role, while clinical and psychopathological variables are prominent. Only history of violence is a robust static predictor. The total level of positive and general psychotic symptoms seems to enhance the violence risk of inpatients, whereas results concerning specific features like delusions or command hallucinations are contradictory due to inevitable problems of sample selection. The accuracy of clinical predictions is better than chance but limited by the effects of therapeutic interventions and research artefacts.

CONCLUSION

The author argues that more precise determinations of the violence risk in institutions will fail and that the role of environmental factors has often been underestimated.

Psychiatric nurses' anxiety and cognition in managing psychiatric patients' aggression

This study explored the anxiety, attitudes, and cognition of the need for aggression management among Taiwanese psychiatric nurses caring for psychiatric patients. Data were collected with self-report questionnaires from 180 psychiatric nurses in the acute wards of three large psychiatric centers in Taiwan. Results showed increased threat of cognitive appraisal of aggression, increased trait anxiety, and decreased positive attitudes toward aggression predicted higher levels of state anxiety. There were significantly higher levels of state anxiety among psychiatric nurses when patients exhibited verbal and physical aggression rather than just physical aggression. An important outcome of this study is the added understanding of cognitive appraisal, trait anxiety, and attitudes, that influence the anxiety of psychiatric nurses.

Impact of training on work-related assault

Although training is often recommended as a part of a comprehensive approach to address occupational violence, little empirical literature exists to support this recommendation. Over 40% of nurses responding to the Minnesota Nurses Study reported being trained about occupational violence, involving seven different training topics. Although at the univariate level, an increased risk was identified for nurses trained in managing assaultive/violent patients, no statistically significant results remained at the multivariate level. This lack of protection from training is consistent with previous research, although the explanations for this lack of effect remain unclear. Additional research is necessary to obtain more specific details on occupational violence training, including training content and methods, to understand more thoroughly the impact of training on occupational violence.

The effects of single session education in reducing symptoms of distress following patient assault in nurses working in medium secure settings

Violence in the workplace is a hazard. Nurses, as a professional group, have the second highest risk of being physically assaulted of all occupational groups. The cost of violent assaults to individuals and organizations is unnecessarily high. This study aimed to explore the effectiveness of a brief educational intervention (reading a booklet on effects of trauma and coping) in reducing distress in nurses working in medium security settings who are physically assaulted by patients. This study found a significant difference in distress score between the education and control group, with education group showing greater distress levels at 3-month follow-up. The study also found a positive correlation between the participant's rating of injury and their feeling of distress.

Violence and schizophrenia: examining the evidence

BACKGROUND

It is now accepted that people with schizophrenia are significantly more likely to be violent than other members of the general population. A less acknowledged fact is that the proportion of societal violence attributable to schizophrenia is small.

AIMS

To critically examine the epidemiological evidence for the association between violence and schizophrenia and estimate the impact of this association on society.

METHOD

A selective review of the key literature on the epidemiology of violence and schizophrenia. Population-attributable risks for violence in schizophrenia are calculated from population-based studies.

RESULTS

Most studies confirm the association between violence and schizophrenia. Recent good evidence supports a small but independent association. Comorbid substance abuse considerably increases this risk. The proportion of violent crime in society attributable to schizophrenia consistently falls below 10%.

CONCLUSIONS

Less focus on the relative risk and more on the absolute risk of violence posed to society by people with schizophrenia would serve to reduce the associated stigma. Strategies aimed at reducing this small risk require further attention, in particular treatment for substance misuse.

Should patients who assault staff be prosecuted?

This article discusses the issue of prosecution of mentally disordered patients particularly in relation to assaults or acts of violence in health care settings. The arguments for prosecuting those responsible for committing acts of dangerous behaviour are discussed, as are the arguments against prosecution and some of the possible reasons why this is a contentious area of discussion. There are significant risks to the integrity of mental health services if the consideration of prosecution as a strategy to reduce risk of violence in hospitals does not become an area of meaningful discussion at all levels. The risk of violence is real, but the risks of accepting it without taking measures to reduce the frequency or severity of violence is no less acceptable than accepting that burglary is inevitable and leaving one's front door ajar every day. Health care professionals may wish to consider that in the absence of a clinically based solution or ownership of the problem, the risk of an organizational response to this sensitive area, perhaps guided or driven by political concerns is likely, as has happened in areas such as risk assessment, treatability and compliance with treatment.

Prediction of violence on a psychiatric intensive care unit

The aim of the present study was to identify patients who were at particular risk of violent behaviour, over a period of one month in a psychiatric high dependency unit, and to examine whether particular patients could be identified at admission who would subsequently be violent. Medical records, and other documents for 52 inpatients were included. Demographic, historical and clinical data available at admission were noted. All violent incidents were recorded and classified. Seventeen of 52 patients committed physical violence, usually to the staff. Most incidents were carried out by a small number of individuals. Identifying the violent, using variables available at admission, was not possible. The ward admitted a group with a subsequent high rate of violence. Prediction within this high-risk group was not possible. Measures aimed at preventing violence on a local secure ward should apply to all patients and should not be targeted just at those that would appear to be the most likely to be violent.

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.

Long-acting antipsychotic medication, restraint and treatment in the management of acute psychosis

OBJECTIVE

Zuclopenthixol acetate (ZA) is the first parenteral antipsychotic medication introduced for clinical use in the treatment of aggression and agitation that has a relatively prolonged duration of action. The aim of this paper is to explore a number of important ethical and clinical issues that are raised by the use of this novel therapeutic formulation.

METHOD

Relevant literature is explored and several issues are identified from which arguments for and against the use of medication of this type are raised. These issues are considered in general and with the use of a number of stylised clinical scenarios.

RESULT

The use of long-acting antipsychotic medication is complicated by its impact upon patient autonomy, by considerations of informed consent and by the need to provide justice to all patients and staff in a psychiatric treatment setting. The use of ZA in the emergency treatment of psychotic patients may only be justified under specific clinical circumstances and its use is not appropriate as routine chemical restraint.

CONCLUSIONS

Zuclopenthixol acetate is a novel and potentially useful treatment alternative in the acutely disturbed patient. Institutions in which ZA is used in emergency settings should develop protocols to guide clinicians in its appropriate use and provide monitoring.

The organizational context of non-lethal workplace violence: its interpersonal, temporal, and spatial correlates

This article examines 993 violent incidents involving faculty, students, and staff that occurred at a highly ranked teaching and research university and its affiliated medical center. Violent incidents were included in the sample if they involved faculty, students, or staff, regardless of their specific location or context (i.e., whether they occurred on campus and/or off-campus and whether they occurred within the context of work or some other activity). The theoretical goal of the project was to compare work-related incidents with non-work-related incidents of interpersonal violence occurring in a single, multifunctioning, and professionally hierarchical organization. Data were collected over a 7-year period from three police departments (city, county, and university), university records, and criminal history records obtained from the state police. The coding protocol was developed to capture crime-scene information pertinent to each of the incidents. This included information about the victim, the perpetrator, the relationship between the victim and perpetrator, and the violent incident. The data were examined using nonparametric statistics and logistic regression to model predictive differences between the workplace and non-workplace incidents. The results suggest that the workplace incidents of violence differ from the non-workplace incidents according to their time, victim age, degree of victim injury, and whether the workplace is a medical location. The authors conclude that these differences are better explained by the movement of people in and out of the workplace who bring societal violence with them, rather than by a category or type of workplace violence.

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.

Risk assessments for acute violence to third parties: a review of the literature

OBJECTIVES

To provide an overview of risk assessments for acute violence to third parties by combining a clinical and research focus and to offer guidelines to physicians conducting clinical assessments.

METHOD

A computerized literature search of the MEDLINE and PSYCHINFO data bases from 1967 to 1996 was completed using the key words violence, aggression, dangerous behaviour, risk, risk assessment, risk factors, and practice guidelines. The search yielded 116 relevant references, 26 of which were original research articles on risk factor identification. A secondary search, based on the citations from the primary search, yielded an additional 8 general discussion articles.

RESULTS

Risk assessments may be conducted using different methods, although all methods should be systematic and comprehensive. Research shows that risk assessments do have validity for use in short-term prediction and that it is possible to develop clinical guidelines in this area. A combined clinical and research approach holds the most promise for improving the accuracy of probability estimates, and most published guides and tools rely on such a combination.

CONCLUSIONS

Risk assessments are an important and necessary part of the clinical examination. Because this field has sufficiently evolved, there is abundant literature to refer to when determining what constitutes an acceptable assessment for risk of violence to third parties and when it is appropriate to conduct such an examination.

Aggressive and violent behavior in a population of psychiatric inpatients

The aim of this observational study was to assess the rates of aggressive and violent behavior in patients admitted to an Italian emergency psychiatric unit and to explore possible risk factors for patient violence. In a population of 313 consecutive patients, we considered aggressive or violent behavior, rated according to a hierarchy from no aggressive behavior to serious physical violence. The results confirm that young age, psychotic symptoms, excitement, akathisia, and diagnosis of personality disorder are risk factors for violent behavior. The unique and major finding of the study is the low prevalence of aggressive and violent acts in this sample of patients, possibly related to their cultural background and to the system of psychiatric care. These data provide supportive evidence for the importance of sociocultural factors in the behavior of psychiatric patients and suggest the need to explore new strategies of prevention and treatment of patient aggression and violence. A non-restraint policy could be a critical factor in reducing violence among psychiatric inpatients.