The extent and effects of violence among psychiatric in-patients

When Trauma Survivors with Psychosis Accuse Staff of Sexual Assault in Inpatient Psychiatric Care

Inpatient psychiatric settings are now known settings in which sexual assault can occur. When a trauma survivor with psychosis makes an accusation of sexual assault within an inpatient setting, staff and the institution are frequently not well equipped in how to respond. While there is scant literature on how to proceed in such dilemmas there is even more of a dearth on how to effectively provide mental health services, trauma- and culturally informed care, and how to best engage with the individual so that safety can be maintained, and treatment continue. This article seeks to convey some basic supports for institutional response, theoretical frameworks to enhance understanding and clinical skill, and shifts in care so that trauma-informed and culturally informed care can take place within these complex dynamics. The goal of this paper is to support mental health services and interdisciplinary teams in becoming more effective in navigating these complex situations so that they can honor and respect the trauma survivor and continue to be effective at providing a healing environment.Public Significance Statement: This article offers enhanced understanding of managing risk and balancing trauma-informed care at an institutional and multi-systemic level when inpatients make allegations of sexual assault. Included in this is enhancing understanding from a theoretical framework of the traumatic experiences of clients, assessing needs and offering safety, treatment, and care, while also managing the complex dynamics and services of the organization.

Sexual assault in the inpatient psychiatric setting

Sexual assault in the inpatient psychiatric setting is a significant problem with serious, lasting consequences. It is important for psychiatric providers to appreciate the nature and magnitude of this problem to be able to provide an appropriate response when faced with these challenging scenarios, as well as to advocate for the implementation of preventive measures. This article provides a review of the existing literature regarding sexual behavior in the inpatient psychiatric unit, describing the epidemiology of sexual assaults in these settings, and exploring the characteristics of both victims and perpetrators, with a particular focus on factors of relevance to the inpatient psychiatric patient population. Inappropriate sexual behavior in inpatient psychiatric settings is common, however the varying definition of such throughout the literature serves as a challenge to clearly identifying the frequency of specific behaviors. The existing literature does not identify a way to reliably predict which patients are most likely to engage in sexually inappropriate behaviors on an inpatient psychiatric unit. The medical, ethical, and legal challenges that such cases present are defined, followed by a review of current management and prevention strategies, and suggested future directions for research.

Gender and intersecting vulnerabilities on the mental health unit: Rethinking the dilemma

Background

Gender is routinely pitched as a key determinant of vulnerability for staff and residents on acute mental health inpatient units. Since the 1960's mixed gender units have become more prominent in Western health systems, yet questions remain around the configuration of these units, including how to ensure emotional and physical safety of those living and working in them.

Methods

This paper draws on a large study of the lived experiences of 42 staff and 43 service users from different acute mental health units in New Zealand. We conducted thematic analysis of interview data from four units with diverse architectural layouts to identify key themes central to decisions around gender and spatial design.

Results

Key themes emerged around gender-related trauma histories, safety perceptions and vulnerabilities, accommodation of gender-diverse and non-binary mental health service users, and gender-specific needs and differences. A further theme, of it goes beyond gender emphasized that there are many other non-gender attributes that influence vulnerability on the unit.

Conclusions

While findings emphasize the need for safe places for vulnerable people, trauma-informed care, access to staff who "understand," and recreation that is meaningful to the individual, we question if the dilemma of gender-separation vs. gender-mixing is an outmoded design consideration. Instead, we argue that a flexible, person-centered approach to provision of care, which values autonomy, privacy, and safety as defined by each service user, and that promotes choice-making, obviates a model where gender accommodations are fore. We found that a gender-exclusive narrative of vulnerability understates the role of other identifiers in dynamics of risk and vulnerability, including age, physicality, past violence, trauma history, mental unwellness, and substance use. We conclude gender need not be a central factor in decisions around design of prospective built unit environments or in occupational and clinical decisions. Instead, we suggest flexible spatial layouts that accommodate multiple vulnerabilities.

Differences between homeless women and men before and after the transition from shelter to community living: A longitudinal analysis

Social quality is the extent to which people are able to participate in social relationships under conditions which enhance their well-being, capacities and potential and enables them to shape their own circumstances and contribute to societal development. We assessed whether women in homeless shelters differed from men on social quality factors that constitute the quality of their daily life and whether factor scores changed at a different rate for women and men after shelter exit. Data were collected as part of a randomised controlled trial. In 18 shelters across the Netherlands, 183 participants were recruited between December 2010 and December 2012 and followed for 9 months. Adults were eligible if they were about to move from shelter to (supported) independent housing and their shelter stay had been shorter than 14 months. At baseline, women were significantly younger than men. They were more likely to have children, to have minor children staying with them, to be lower educated, to be unemployed and to have been victimised than men. Women had used more services and reported lower self-esteem, less satisfaction with health and empowerment and higher psychological distress. They were less likely than men to have used alcohol excessively or cannabis. We found no significant differences between women and men in changes over time on the social quality factors. As women were disadvantaged at baseline compared to men regarding many factors, we concluded that women in homeless shelters are a particularly vulnerable group. Moreover, an opportunity remains for shelter services to improve women's social quality during and after their shelter stay.

Developing a policy to deal with sexual assault on psychiatric in-patient wards

Sexual harassment and assault on psychiatric wards is an ongoing concern. A number of incidents have been reported in the media. This paper focuses on a policy drafted to deal with allegations of sexual assault or rape on an in-patient psychiatric ward. We aimed to produce a practical, easy-to-follow guide for junior doctors and ward staff who may face complex and possibly contentious issues surrounding consent, capacity to consent and police involvement.

Violence, dissatisfaction and rapid tranquillisation in psychiatric intensive care

We examined the associations of violence, patient dissatisfaction and occurrence of rapid tranquillisation in psychiatric intensive care, using an on-line nurse-based computerised database over a two-year period. Non-Caucasians were over-represented in violent incidents with physical threat, and previous forensic history was associated with more violent means of attack. Dissatisfaction related to non-understandable provocation and the total number of violent incidents. There was no correlation between rapid tranquillisations or side-effects and dissatisfaction. Remedial action and education in the psychiatric intensive care unit may reduce violence, and better prescribing habits, avoiding anti-psychotic polypharmacy in rapid tranquillisation, should be encouraged.

Sexual assaults in psychiatric in-patient units: the importance of a consistent approach

Aims and Method

In order to establish whether there is consistency in the management of sexual assault allegations in a psychiatric in-patient unit, and to assess quality of data recording, a manual search of 177 case notes included in an audit project, carried out between October 1997 and May 1999 was carried out. Each recorded allegation was noted on a standard form.

Results

There was little consistency between cases, and data recording was patchy.

Clinical Implications

There is no accurate method of recording or monitoring alleged sexual assault in the trust studied. In spite of a policy document, these cases are dealt with ad hoc.

Do women need special secure services?

Clinicians working with women patients in secure units will already know that they are the centre of a debate not of their own making, which is about the appropriate specification of services for women patients with security needs. This paper attempts to outline the relevant issues and proposed solutions.

Good practice issues in psychiatric intensive-care units

Aims and method

To survey some aspects of care relevant to good practice in psychiatric intensive-care units.

Results

A number of areas of concern were identified, including care issues for informal and female patients, a lack of uniform clinical leadership and a paucity of policies/guidelines for high-risk areas of clinical practice.

Clinical implications

In an attempt to provide a service for the most disturbed patients from widely varying sources, psychiatric intensive-care units are at risk of compromising the ability to provide good-quality clinical care.

Safety and security: a survey of female psychiatric in-patients

Fifty-three female in-patients of a psychiatric hospital were interviewed to obtain their views on their own safety and security, and what improvements they would recommend. Most had experienced sexual harassment and a few had been victims of sexual assault. There was a reluctance to report incidents to staff. The majority felt that female-only wards would improve safety. Other recommendations included higher staffing levels, more staff awareness and vigilance, and single rooms with curtains on the doors.

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.

Addressing the sexual and reproductive health needs of women who use mental health services

Pregnancies in women with serious mental illness are high risk and such women are also less likely to engage in the recommended health screening for women of reproductive age. Hence, reproductive health issues are important aspects of physical healthcare that should be assessed in women accessing mental health services. Pregnancy planning and management are crucial in reducing risk of relapse in women with affective disorders, and psychiatrists should acquaint themselves with the screening programmes and reproductive and sexual health services in their area and encourage their patients' uptake of these. Clinicians should be aware of the reproductive impact of medications and the needs of specific groups of women.

Sexual behaviours on acute inpatient psychiatric units

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

Criminal victimisation in people with severe mental illness: a multi-site prevalence and incidence survey in the Netherlands

Background

Although crime victimisation is as prevalent in psychiatric patients as crime perpetration (and possibly more so), few European figures for it are available. We therefore assessed its one-year prevalence and incident rates in Dutch severely mentally ill outpatients, and compared the results with victimisation rates in the general population.

Method

This multisite epidemiological survey included a random sample of 956 adult severely mentally ill outpatients. Data on victimisation were obtained using the victimisation scale of the Dutch Crime and Victimisation Survey, which assesses crime victimisation over the preceding 12 months. Comparison data were derived from the nationwide survey on safety and victimisation in the Netherlands. Prevalence and incident rates were weighted for sex, age, ethnicity and socioeconomic status, and compared with a general population sample matched by region (N = 38,227).

Results

In the past year, almost half of the severely mentally ill outpatients (47%) had been victim of a crime. After control for demographic differences, prevalence rates of overall and specific victimisation measures were significantly higher in severely mentally ill outpatients than in the general population. The relative rates were especially high for personal crimes such as violent threats (RR = 2.12, 95% CI: 1.72–2.61), physical assaults (RR = 4.85, 95% CI: 3.69–6.39) and sexual harassment and assaults (RR = 3.94, 95% CI: 3.05–5.09). In concordance, severely mentally ill outpatients reported almost 14 times more personal crime incidents than persons from the general population (IRR = 13.68, 95% CI: 12.85–14.56).

Conclusion

Crime victimisation is a serious problem in Dutch severely mentally ill outpatients. Mental-healthcare institutions and clinicians should become aware of their patients’ victimisation risk, and should implement structural measures to detect and prevent (re-)victimisation.

Consultant psychiatrists' experience of workplace violence - a national survey

OBJECTIVES

In recent years there have been a number of high profile cases in Irish psychiatry where consultant psychiatrists have been subjected to serious physical assaults. The last survey of assaults on consultant psychiatrists in Ireland was carried out in 1998. Therefore we sought to update the data on this topic.

METHOD

An anonymous questionnaire was sent out by post to all consultant psychiatrists (n = 330) identified as currently working in the Republic of Ireland.

RESULTS

The response rate was 48.2%. Sixty per cent of respondents were working in general adult psychiatry and respondents were evenly spread throughout the country. Ninety per cent of respondents had been the victim of verbal aggression/intimidation/threatening behaviour while 55% had been physically assaulted. The majority of incidents involved male patients aged between 21-40 years with a diagnosis of paranoid schizophrenia. Nearly 66% of incidents of physical violence occurred during a relapse of illness. The perpetrator had a history of violence in approximately half of all reported incidents. Physical assaults tended to occur more commonly in inpatient settings (63.7%). Incident reporting occurred more often in physical assaults with 66% reported informally to colleagues and 20% reported to An Garda Siochana (police force of Ireland). Eighty-nine (56%) consultants described feeling 'safe' at work. Less than 50% reported the provision of standard safety equipment in the workplace and nearly half ofrespondents had not attended any safety training courses since their appointment. Longer experience working as a consultant psychiatrist did not appear to have an impact on reducing the rate of assaults. In addition, those who attended safety training courses did not report a reduced rate of physical assaults.

CONCLUSIONS

These findings highlight the need for both organisational and personal changes in practice in order to reduce the assault rate. Organisational changes include the provision of appropriate safety equipment, safety training for consultants, enhancing multidisciplinary teams and utilising risk assessment. Consultants' personal practices to improve their safety may offer useful information for inclusion in safety training courses. This is an area which merits further research.

Safety of women in mixed-sex and single-sex medium secure units: staff and patient perceptions

BACKGROUND

The development of single-sex medium secure units for women has been driven by concern about the vulnerability of women to sexual abuse and exploitation in mixed-sex secure settings. Less is known about how women patients and staff perceive gender segregation and their experiences in single-sex units.

AIMS

To examine the impact of gender segregation on the safety of women patients detained in medium secure psychiatric facilities.

METHOD

A qualitative study was conducted involving individual interviews with 58 male and female staff and 31 women patients in single-sex and mixed-sex medium secure units throughout England and Wales.

RESULTS

Women patients in both types of units reported high levels of actual and threatened physical and sexual violence. Women in single-sex units reported intimidation, threats and abuse by other women patients, although they were less vulnerable to sexual abuse and exploitation and serious physical assault.

CONCLUSIONS

Further development of single-sex secure units for women may not be justified on the grounds of safety issues alone. Risk assessment of forensic psychiatric patients must include a full assessment of their safety within the psychiatric setting.

Development of a specialised forensic service for women with learning disability: the first three years

In recent years there has been growing interest in the fate of those women with mental disorder who come into contact with the criminal justice system. This interest has stemmed from growing recognition that traditional forensic services could not offer the appropriate care required by this group in a conventional mixed‐gender environment. Women‐only services have begun to be developed in generic psychiatric settings, spurred on by the national service framework (NSF) which set a time limit for the development of segregated in‐patient facilities. Forensic services for those with learning disability have been slower to take up the challenge of how best to place women with learning disability who offend and require an in‐patient secure environment. This article describes how one such service attempted to rise to this challenge and build a service for this often neglected group

Sex and segregation: Staff attitudes explored

INTRODUCTION The aim of the study was to establish whether there was consistency of opinion amongst staff about mixed sex wards and the sexual activity of inpatients. Also to establish what demographic factors, if any, modulated those opinions. METHOD A 17-item, five-point, questionnaire was supplied to all medical and nursing staff working on five wards of a psychiatric inpatient unit. Demographic details of the respondents were also recorded. RESULTS Some items produced almost unanimous responses: 92.5% agreeing or strongly agreeing that some inpatients form sexually active relationships that are detrimental to their health. Staff felt that single sex wards should be available but were unsure that they would improve quality of life for either patients or staff. The strongest factor predicting response was profession (doctor or nurse), the responses being significantly different in eight of the 17 items. Doctors were more likely to believe that women's and staff's lives would be better on single sex wards and were less likely to be satisfied with current arrangements. They were also more likely to believe that sex was common among inpatients, and that there was an unofficial place to go in hospitals to have sex. Doctors worried more about the patient choice of sexual partner and believed that health workers should have a role in influencing that choice. Doctors also felt more strongly that patients sometimes form sexually active relationships of benefit to health. Ward was the next most important, being significantly different in four of the 17 questions. Gender and age of respondents produced few differences. CONCLUSIONS In view of the United Kingdom government commitment to phasing out mixed sex hospital accommodation by 2002 (Safety, privacy and dignity in mental health units - Guidance on mixed sex accommodation, Department of Health, 2000), the doubts of staff about improvement to inpatient quality of life, and their own quality of working life need to be further examined. Staff attitudes generally are more likely to be determined by job or ward of employment than the staff's gender, age, or experience of psychiatry. This may have implications in tailoring training schemes for staff of inpatient psychiatric units.

Sexual assault on wards: Staff actions and reactions

INTRODUCTION The aim of the study was to look at staff practices when patients had been sexually assaulted, and to look at their emotions around an event that normally causes outrage amongst those who deal with it. METHODS A 16-item, five-point questionnaire was supplied to all medical and nursing staff working on five wards of a psychiatric inpatient unit. Demographic details of respondents and their work experience of sexual assault (defined as all forms of sexual touching without consent, including rape) were also noted. There were four additional questions inviting a free text response. Two questions were posed about inpatient sexuality in general, and two about sexual assault. RESULTS Staff generally agreed about what action should be taken in cases of sexual assault and, except for anger, experienced low levels of negative emotions when dealing with cases amongst patients. However, weariness was a key emotion, correlating with post held, levels of anger, depression, and likelihood of helping the patients inform the police. Consultants were the most weary professional group. Free text written responses revealed widespread concern amongst staff that women inpatients forming sexual relationships are vulnerable to exploitation and abuse, and that staff will be blamed in the event of sexual assault. CONCLUSION Policy documents should specifically address issues around staff intervention in inpatients' sexual lives.

The content of management of violence policy documents in United Kingdom acute inpatient mental health services

AIM OF THE STUDY

The aim of the study was to examine the content of Trust policies concerning the prevention and management of violence in acute in-patient settings in order to establish their usefulness as guidance for staff in this difficult, complex, and controversial aspect of inpatient psychiatric care.

BACKGROUND

Violence is a commonly encountered problem in inpatient psychiatric settings. There are legal requirements for workplaces in general and mental health care facilities in particular to develop safe systems of work based upon the findings of assessments of this risk. Policies have a key role to play in making explicit the responsibilities of both employer and employees, and specifying standards of acceptable practice.

DESIGN

A cross-sectional survey methodology was used, which entailed examination of the content of management of violence policies that had been forwarded to the authors from 40 Trusts providing acute inpatient psychiatric care throughout England, Scotland, Wales, and Northern Ireland.

FINDINGS

Policies were found to vary widely in their content, and serious shortcomings were noted in the extent to which policies included information regarding their status and review, advice on the prevention of violence, the management of violent incidents, and postincident action.

CONCLUSIONS

Further research is needed to tease out the extent to policies which are lacking in content, reflect shortcomings in the organizational approach to the prevention and management of violence by Trusts, and the extent to which such shortcomings result in harm being suffered by staff and/or patients. An alternative format for the presentation of management of violence policies is discussed, and items that should be included in inpatient units' management of violence policies are suggested.

Client empowerment in psychiatry and the professional abuse of clients: where do we stand?

OBJECTIVE

There is a considerable imbalance of power in psychiatry that sits in favor of professionals. The abuse and discrimination of the mentally ill are not just restricted to the mental health system but may also exist in the primary care sector. This article aims to evaluate the effects of power imbalance on discrimination and abuse of people with mental illness by professionals.

METHODS

A literature search was carried out on MEDLINE using the key words consumerism, client empowerment, abuse, and mental illness. Publications of two leading British consumer organizations: MIND and the Sainsbury Centre for Mental Health were hand searched. Relevant cross-references from the papers reviewed were consulted. Studies with information on the reasons for power imbalance and prevalence of discrimination and abuse of clients were critically reviewed. Explanations are offered as to why abuse and discrimination of clients by professionals may still occur despite the onset of the client empowerment movement.

RESULTS AND DISCUSSION

The available evidence suggests that reasons for abuse of mental health clients fall under two broad categories: 1) direction from the imbalance of power and 2) those pertinent to the nature of physical or sexual abuse. Different grades of client empowerment and ways of strengthening it are described.

CONCLUSIONS

There appears to be a link between power imbalance and abuse of clients with mental illness by professionals in all health care sectors. Client empowerment may help rectify the power imbalance. Prospective studies are required to establish whether client empowerment can reduce discrimination and abuse of clients and whether abuse is a consequence of power imbalance. Recommendations for future studies are made.

Satisfaction with in-patient psychiatric services. Relationship to patient and treatment factors

BACKGROUND

There is growing concern about patient satisfaction with psychiatric in-patient provision. This paper measures satisfaction in psychiatric in-patients and its relationships with patient characteristics and ward experiences.

AIMS

To: (a) measure overall in-patient satisfaction; (b) examine its relationship to in-patient experiences; and (c) examine its relationship to patient factors.

METHOD

Four hundred and thirty-three patients were interviewed. Satisfaction was assessed by a single quest on, the Client Satisfaction Questionnaire (CSQ) and by a semistructured interview.

RESULTS

Over three-quarters of the patients were satisfied, but two-thirds reported adverse events. Females, younger patients and those detained were more dissatisfied. No significant relationship was found for ethnic group. Results were similar in the mental hospital and district general hospital.

CONCLUSIONS

There remain problems with satisfaction scales. Qualitative approaches to examine patients' experiences in hospital and the causes of dissatisfaction are recommended.

Nursing acute psychiatric patients: a quantitative and qualitative study

Political and managerial attention has focused on the consequences of the failure of community services to provide effective care to a small number of people with severe mental illness. However, the nature and value of care in hospitals have received less scrutiny. This paper addresses deficiencies in our knowledge about nursing care in acute psychiatric wards. It reports the findings from a recently completed study for the United Kingdom Department of Health. Four key developments are identified which, together, pose significant problems for nursing in acute wards: the increasingly diverse patient mix in wards; the volume of administrative duties performed by nurses; the weakness of multidisciplinary team working; and inappropriate education. In conclusion, the challenges for managers and clinicians responsible for local policy and practice and, by extension, those at the centre responsible for such services, are examined.