Strategies for the Prevention of Violence in Institutional Care: A Qualitative Interview Study With Ward Managers

BACKGROUND

The presence of violence within psychiatric and residential settings remains a challenge. Research on this problem has often focused on describing violence prevention strategies from either staffs' or service users' perspectives, and the views of ward managers has been largely overlooked. The aim of the present study was therefore to identify ward managers' strategies to prevent violence in institutional care, focusing on safety and values.

METHODS

Data were collected using semi-structured interviews with 12 ward managers who headed four different types of psychiatric wards and two special residential homes for adolescents. Qualitative content analysis was applied, first using a deductive approach, in which quotes were selected within a frame of primary, secondary, and tertiary prevention, then by coding using an inductive approach to create themes and subthemes.

RESULTS

Ward managers' strategies were divided into the four following themes: (1) Balancing being an active manager with relying on staff's abilities to carry out their work properly while staying mostly in the background; (2) Promoting value awareness and non-coercive practices in encounters with service users by promoting key values and adopting de-escalation techniques, as well as focusing on staff-service user relationships; (3) Acknowledging and strengthening staff's abilities and competence by viewing and treating staff as a critical resource for good care; and (4) Providing information and support to staff by exchanging information and debriefing them after violent incidents.

CONCLUSIONS

Ward managers described ethical challenges surrounding violence and coercive measures. These were often described as practical problems, so there seems to be a need for a development of higher ethical awareness based on a common understanding regarding central ethical values to be respected in coercive care. The ward managers seem to have a high awareness of de-escalation and the work with secondary prevention, however, there is a need to develop the work with primary and tertiary prevention. The service user group or user organizations were not considered as resources in violence prevention, so there is a need to ensure that all stakeholders are active in the process of creating violence prevention strategies.

Midwives' perception of patient safety culture-A qualitative study

OBJECTIVE

To explore midwives' experiences with and perceptions of patient safety culture in the German-speaking countries.

DESIGN AND SETTING

Semi-structured interviews with midwives were conducted between December 2013 and March 2014, whereby the narrative nature of the questions on patient safety culture provided the space for the interviewed midwives to express their own wishes and thoughts freely. The interviews were recorded and transcribed, and the transcripts were anonymized with respect to personal and institutional names. The analysis of the transcripts was based on the methods of qualitative content analysis with the goal to consider all of the remarks with open coding, following a strictly inductive approach. Data analysis and categorization was performed using the software MAXQDA Release 12.2.1.

PARTICIPANTS

14 midwives from Austria, Germany and Switzerland.

FINDINGS

The interviewed midwives provided insights into their thoughts and experiences on factors that promote and inhibit patient safety culture as well as superordinate topics related to patient safety culture in general. Their statements were assigned to seven main categories; (i) institutional circumstances, (ii) role of the management, (iii) interprofessional factors, (iv) meetings, (v) education and training, and (vi) psychosocial aspects. Moreover, the majority of statements assigned to these categories additionally related to two overarching core categories, communication and knowledge / skills.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

It appears that patient safety culture is a personal matter for the majority of the participating midwives. However, it seems that at least at some institutions a discrepancy between the perceived importance of patient safety culture and an incomplete implementation into everyday work exists. A natural way of dealing with patient safety culture and an open blame-free discussion of critical incidences rely on the implementation of institutional circumstances that promote education, training as well as intra- and interprofessional exchange and transparent clear responsibilities.

Use of a single parameter track and trigger chart and the perceived barriers and facilitators to escalation of a deteriorating ward patient: a mixed methods study

AIMS AND OBJECTIVES

To investigate nurses' use of a single parameter track and trigger chart to inform implementation of the National Early Warning Scoring tool. To report the characteristics of patients with triggers, the frequency of different triggers, and the time taken to repeat observations. To explore the barriers and facilitators perceived by nursing staff relating to patient monitoring.

BACKGROUND

Sub-optimal care of the deteriorating patient has been described for almost two decades. Organisations have responded by implementing strategies that improve monitoring and facilitate a timely response to patient deterioration. While these systems have been widely adopted the evidence-base to support their use is inconsistent.

DESIGN

A mixed method service evaluation was carried out in an acute University hospital.

METHODS

Physiological triggers (n = 263) and characteristics of triggering patients (n = 74) were recorded from surgical and medical wards. Descriptive statistics were displayed. Questionnaires were distributed (n = 105) to student nurses, health care assistants and registered nurses. Themes and sub-themes were identified from content analysis.

RESULTS

Hypotension was the most frequent abnormality. There was variability in the time to repeat observations following a trigger. A high proportion of triggers were identified in older patients, as was a trend of longer time intervals between trigger and repeat observations. Nurses reported a number of barriers and facilitators to monitoring patients including: 'workload', 'equipment', 'interactions between staff' and 'interactions with patients'.

CONCLUSIONS

This study identified a number of barriers and facilitators to monitoring and escalation of abnormal vital signs, highlighting the complexity of the process and the need for a system-wide approach to a deteriorating patient.

RELEVANCE TO CLINICAL PRACTICE

The trend of longer delays following a trigger in older patients has not been identified previously and could reflect a knowledge gap of the physiological changes and response to acute illness in older people.