Violence within mental health services: how to enhance risk management

Behavioral skills training for teaching safety skills to mental health service providers compared to training-as-usual: a pragmatic randomized control trial

BACKGROUND

Violence in the healthcare workplace has been a global concern for over two decades, with a high prevalence of violence towards healthcare workers reported. Workplace violence has become a healthcare quality indicator and embedded in quality improvement initiatives of many healthcare organizations. The Centre for Addiction and Mental Health (CAMH), Canada's largest mental health hospital, provides all clinical staff with mandated staff safety training for self-protection and team-control skills. These skills are to be used as a last resort when a patient is at imminent risk of harm to self or others. The purpose of this study is to compare the effectiveness of two training methods of this mandated staff safety training for workplace violence in a large psychiatric hospital setting.

METHODS

Using a pragmatic randomized control trial design, this study compares two approaches to teaching safety skills CAMH's training-as-usual (TAU) using the 3D approach (description, demonstration and doing) and behavioural skills training (BST), from the field of applied behaviour analysis, using instruction, modeling, practice and feedback loop. Staff were assessed on three outcome measures (competency, mastery and confidence), across three time points: before training (baseline), immediately after training (post-training) and one month later (follow-up). This study was registered with the ISRCTN registry on 06/09/2023 (ISRCTN18133140).

RESULTS

With a sample size of 99 new staff, results indicate that BST was significantly better than TAU in improving observed performance of self-protection and team-control skills. Both methods were associated with improved skills and confidence. However, there was a decrease in skill performance levels at the one-month follow-up for both methods, with BST remaining higher than TAU scores across all three time points. The impact of training improved staff confidence in both training methods and remained high across all three time points.

CONCLUSIONS

The study findings suggest that BST is more effective than TAU in improving safety skills among healthcare workers. However, the retention of skills over time remains a concern, and therefore a single training session without on-the-job-feedback or booster sessions based on objective assessments of skill may not be sufficient. Further research is needed to confirm and expand upon these findings in different settings.

Effects of Workplace Violence on Emotional Distress

The current study assessed the effects of workplace violence (WPV) and fear related to WPV on community mental health (CMH) workers' emotional distress. This cross-sectional study used structural equation modeling (SEM) and comprised participants who were CMH workers in Korea. We used WPV questionnaires and the Korean version of the Patient-Reported Outcomes Measurement Information System® item bank to evaluate emotional distress. SEM data from 763 workers revealed significant positive effects of WPV on anxiety (β = 0.23, p = 0.009) and anger (β = 0.26, p = 0.007), and significant positive effects of fear related to WPV on anxiety (β = 0.21, p = 0.004) and anger (β = 0.19, p = 0.002). Preventive measures significantly mediated the relationship between WPV and emotional distress and between fear related to WPV and emotional distress. Findings verified the relationship between WPV and workers' emotional distress and the mediating role of preventive measures. [Journal of Psychosocial Nursing and Mental Health Services, 62(4), 24-32.].

Unveiling the Prevalence and Factors of Workplace Bullying in Primary Healthcare Settings: A Cross-Sectional Study in Jeddah City, Saudi Arabia

Introduction Bullying in workplaces can lead to serious and deleterious effects on both the health and well-being of individuals. In a healthcare environment, bullying can lead to life-threatening adverse outcomes for patients and healthcare workers. The aim of this study was to evaluate the prevalence and factors of bullying among primary healthcare workers in Jeddah, Saudi Arabia. Methods This cross-sectional study targeted physicians and nurses in Jeddah healthcare centers and used a Negative Acts Questionnaire-Revised (NAQ-R) to evaluate participants' exposure to bullying. The chi-square test was used to examine the relationship between the outcome and other variables. Results The majority of participants (59.8%) had more than 10 years of experience and were nurses (56.6%). The majority of participants (69.4%) scored below 33 on the NAQ-R scale, while 19.9% scored between 33 and 45, and 10.7% scored over 45. Most perpetrators were references/patients (22.4%), supervisors (19.2%), department managers, or general managers (19.2%). Of all participants, 28.8% had experienced workplace bullying (WPB), and 31.7% witnessed it over the past five years. Being subjected to WPB (P < 0.001), being bullied by a manager (P < 0.001), and experiencing and witnessing WPB over the past five years (P < 0.001) correlated with higher NAQ-R scores. Years of experience were significantly associated with NAQ-R scores (P = 0.016). Conclusions This study indicates bullying among a third of healthcare workers, mainly perpetrated by patients and managers. Years of experience and manager offenses, experiencing and witnessing WPB were associated with higher bullying rates. Therefore, there is an urgent need for antibullying policies, awareness campaigns, education programs, effective communication, conflict resolution, leadership training, and transparent culture to address this problem.

Incidents related to safety in mental health facilities in Kenya

BACKGROUND

Both patients and health care providers working in mental health facilities witness high rates of incidents that have the potential to jeopardize their safety. Despite this, there are few studies that have documented the kind of incidents that are experienced, or explored the potential contributors to these incidents, and solutions that would result in better safety. This study explored various types of safety related incidents occurring in mental facilities in Kenya, perceived contributing factors, and recommendations for improve.

METHODS

This qualitative descriptive study was carried out between December 2019 - February 2020. It included 28 mental health staff across 14 mental health unit spread across the country.

RESULTS

All the participants reported having personally experienced an incident that threatened their safety or that of the patients. Most of the respondents (24/26. 91.67%) admitted to have experienced verbal aggression while 54.17%, (n = 24) had experienced physical assault. Participating health care workers attributed the safety incidents to poor infrastructure, limited human resources, and inadequate medication to calm down agitated patients. Suggested solutions to improve patient safety included; improving surveillance systems, hiring more specialized healthcare workers, and provision of adequate supplies such as short-acting injectable psychotropic.

CONCLUSION

Incidents that threaten patient and staff safety are common in mental health facilities in Kenya. There is need to strengthen staff capacity and reporting mechanisms, as well as invest in infrastructural improvements, to safeguard patient and staff safety in mental health facilities in Kenya.

Behavioral Skills Training for Teaching Safety Skills to Mental Health Clinicians: Protocol for a Pragmatic Randomized Control Trial

BACKGROUND

Workplace violence is an increasingly significant topic, particularly for staff working in mental health settings. The Centre for Addiction and Mental Health (CAMH), Canada's largest mental health hospital, considers workplace safety a high priority and consequently has mandated staff safety training. For clinical staff, key components of this training are self-protection and team-control skills, which are a last resort when an individual is at an imminent risk of harm to self or others and other interventions are ineffective (eg, verbal de-escalation). For the past 20 years, CAMH's training-as-usual (TAU) has been based on a 3D approach (description, demonstration, and doing), but without any competency-based assessment. Recent staff reports indicate that the acquisition and retention of these skills may be problematic and that staff are not always confident in their ability to effectively address workplace violence. The current literature lacks studies that evaluate how staff are trained to acquire these physical skills and consequently provides no recommendations or best practice guidelines. To address these gaps described by the staff and in the literature, we have used an evidence-based approach from the field of applied behavior analysis known as behavioral skills training (BST), which requires trainees to actively execute targeted skills through instruction, modeling, practice, and feedback loop. As part of this method, competency checklists of skills are used with direct observation to determine successful mastery.

OBJECTIVE

Our objectives are to evaluate the effectiveness of BST versus TAU in terms of staff confidence; their competence in self-protection and team-control physical skills; their level of mastery (predefined as 80% competence) in these skills; and their confidence, competency, and mastery at 1 month posttraining.

METHODS

We are using a pragmatic randomized controlled trial design. New staff registering for their mandatory safety training are randomly assigned to sessions which are, in turn, randomly assigned to either the BST or TAU conditions. Attendees are informed and consented into the study at the beginning of training. Differences between those consenting and those not consenting in terms of role and department are tracked to flag potential biases.

RESULTS

This study was internally funded and commenced in January 2021 after receiving ethics approval. As of May 2022, data collection is complete; half of the baseline, posttraining, and 1-month videotapes have been rated, and three-fourths of the interrater reliability checks have been completed. The analysis is expected to begin in late summer 2022 with results submitted for publication by fall 2022.

CONCLUSIONS

The findings from this study are expected to contribute to both the medical education literature as well as to the field of applied behavioral analysis where randomized controlled trial designs are rare. More practically, the results are also expected to inform the continuing development of our institutional staff safety training program.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/39672.

Factors associated with workplace violence among healthcare workers in an academic medical center

PURPOSE

We examined demographic, work-related, and behavioral factors associated with witnessing and/or experiencing workplace violence among healthcare workers.

DESIGN AND METHODS

Utilizing a correlational design, we analyzed the data to determine the associative factors related to workplace violence among the participants.

FINDINGS

More than half of the participants (54.5%) reported witnessing (23.8%) or experiencing (30.7%) workplace violence. There were significant differences between health provider groups in witnessing or experiencing workplace violence (Χ²  = 41.9[df12], p < 0.0001). Moreover, the experience of workplace violence differed by practice setting (Χ²  = 65.9[df14], p < 0.0001), with highest rates occurring in psychiatric (45.1%) and emergency (44.1%) services.

PRACTICE IMPLICATIONS

Findings may inform research, policies, and practice interventions to assess risks for workplace violence and implement preventative policies within high-risk professional groups and settings.

Safewards Secure: A Delphi study to develop an addition to the Safewards model for forensic mental health services

WHAT IS KNOWN ON THE SUBJECT?: The Safewards model has been introduced to forensic mental health wards with mixed results. Research has identified a need to consider the addition of factors that may be relevant to forensic mental health services to enhance the introduction of Safewards. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This study elicits factors specific to forensic mental health settings missing from the original Safewards model, which have the potential to enhance nursing care, improve safety and improve adherence to Safewards in a forensic mental health setting. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This study provides the adaptation required in a forensic mental health setting to enhance the implementation of the Safewards model of care, originally developed to assist nurses to prevent and manage conflict and containment in acute general mental health settings. The development of Safewards Secure has incorporated perspectives from expert Safewards and forensic mental health nurse leaders and healthcare clinicians and is inclusive of consumer and carer perspectives to ensure the model is applicable and broadly acceptable. ABSTRACT: Introduction Safewards is a model designed specifically for acute mental inpatient wards. Research investigating the introduction of Safewards has identified a need to consider factors relevant in forensic mental health services, such as offence and risk issues. Aim To identify adaptations needed to address gaps in the Safewards model to assist forensic mental health nurses to prevent and manage conflict and containment. Method A Delphi study was employed to engage a group of international Safewards and forensic mental health experts (n = 19), to elucidate adaptation of the Safewards model. Results Experts identified necessary elements and reached consensus on key considerations for Safewards interventions. To ensure the Safewards Secure model was robust and developed on a platform of research, all items suggested by Delphi experts were cross-referenced and dependent on empirical evidence in the literature. Discussion This study identified a number of key differences between civil and forensic mental health services, which informed the development of Safewards Secure, an adjunct to the original Safewards model. Implications for Practice The development of person-centred models of nursing care adapted to specific settings, such as forensic mental health, provides a potential solution to preventing and managing conflict and containment, and improving consumer outcomes. Relevance Statement Managing conflict and containment in mental health services remains an ongoing challenge for mental health nurses. Safewards is a model of care designed for acute mental health inpatient settings to prevent conflict and containment. To date, there has been mixed results when introducing Safewards in forensic mental health settings, and reported reluctance and scepticism. To address these issues, this study employed a Delphi design to elicit possible adaptions to the original Safewards model. From this study, Safewards Secure was developed with adaptations designed for forensic services, to enhance the management of conflict and containment, assist implementation and improve consumer outcomes.

Workplace bullying in surgical environments in Saudi Arabia: A multiregional cross-sectional study

BACKGROUND

Workplace bullying (WPB) is any sort of repeated and unjustified verbal, sexual, or physical intimidation that a person is exposed to by a group or another person in the workplace. In healthcare environments, practitioners are occasionally victims of WPB incidents. Bullying in surgical environments is an important issue that needs attention as it could affect patient care either directly or indirectly. The objective of this study was to assess the prevalence of bullying in surgical environments in multiple regions in Saudi Arabia.

MATERIALS AND METHODS

This cross-sectional study was conducted among surgeons, trainees, interns, nurses, and students in surgical specialties in multiple Saudi regions. The survey was designed by Survey Monkey and posted online. The data were analyzed through SPSS Version-21 by computing descriptive statistics as frequency and percentages with graph construction.

RESULTS

About two-thirds (65.2%) of the 788 study participants were male and were between the age of 20 and 29 years (67.8%). Consultants came first as perpetrators of bullying in the past 12 months (44.3%) and residents and interns were the major victims. The NAQ-R score ranged from 22.00 to 110.00, with a mean score of 42.47 (SD=17.9). Statistically significant association was found between mean NAQ-R score and age (P = 0.007), specialty (P = 0.002), and position (P < 0.001).

CONCLUSION

WPB is a pervasive problem in surgical environments in multiple regions of Saudi Arabia. Consultants and specialists are the primary offenders in bullying, which makes the hospital an environment for bullying behaviors.

The Effects of a Psychodrama-Based Risk Management Training Program on the Knowledge and Practices of Turkish Nurses in Psychiatric Clinics

This study aimed to assess the effects of a psychodrama-based risk management training program on nurses' knowledge and practices. This study used a mixed methods design; quantitative and qualitative methods were used together with a single group pretest, post-test, and follow-up. The training program, in which the nurses took part, comprised six lessons that were designed using psychodrama methods. The result showed that risk management scores increased significantly after the training. Thus, this training is effective for improving the knowledge and practices of mental health nurses for risk management.

Six things to know about the homicides of doctors: a review of 30 years from Italy

Background

Healthcare workers have a 16 times greater risk of suffering workplace violence than workers in other sectors and around 50% experience workplace violence in the course of their career. The objective of this study is to explore the characteristics and circumstances of work-related killings of doctors.

Methods

Work-related homicides of doctors over the period 1988–2019 were identified retrospectively through the Italian national statistical agencies. Variables such as perpetrator, motive and location of the crime were obtained through forensic psychiatric work. After classification, the absolute and percent values of the main characteristics of the homicides were calculated.

Results

Over the period considered, 21 doctors were killed in Italy in connection with their professional activity. In 52% (n = 11) of cases, the killer was one of the doctor’s patients, in 29% (n = 6) of cases it was a patient’s relative, in 19% (n = 4) an occasional patient (first consultation). The location of the homicide was a community clinic in 48% (n = 10) of cases, the street in 19% (n = 4) of cases, the doctor’s home in 14% (n = 3), the hospital in 14% (n = 3) and the patient’s home in 5% (n = 1). In 57% (n = 12) of cases the perpetrator was not affected by any mental disorders. The motive for the homicide was revenge in 66.7% (n = 14) of cases; in 28.6% (n = 6) the revenge was preceded by stalking.

Conclusions

Doctors should be aware that the risk of being killed is not limited to hospital settings and that their patients’ family members might also pose a threat to them.

Work-related violence and depressive disorder among 955,573 employees followed for 6.99 million person-years. The Danish Work Life Course Cohort study: Work-related violence and depression

BACKGROUND

We examined the association between probability of work-related violence and first diagnosis of depressive disorder whilst accounting for the potential selection of individuals vulnerable to depression into occupations with high probability of work-related violence.

METHODS

Based on a pre-published study protocol, we analysed nationwide register data from the Danish Work Life Course Cohort study, encompassing 955,573 individuals followed from their entry into the workforce, and free from depressive disorder before work-force entry. Depressive disorder was measured from psychiatric in- and outpatient admissions. We measured work-related violence throughout the worklife by the annual average occupational risk of violence exposure. Using Cox proportional hazards regression, we examined the longitudinal association between work-related violence (both past year and cumulative life-long exposure) and first depressive disorder diagnosis, whilst adjusting for numerous confounders including parental psychiatric and somatic diagnoses, childhood socioeconomic position, and health services use before workforce entry.

RESULTS

The risk of depressive disorder was higher in individuals with high probability of past year work-related violence (hazard ratio: 1.11, 95% CI: 1.06-1.16) compared to employees with low probability of exposure, after adjustment for confounders. Among women, associations were robust across industries, whereas among men, associations were limited to certain industries.

LIMITATIONS

Violence was measured on the job group and not the individual level, likely resulting in some misclassification of the exposure.

CONCLUSIONS

Work-related violence may increase the risk of depressive disorder, independent of pre-existing risk factors for depressive disorder. These findings underline the importance of preventing work-related violence.

Supporting mental health staff following exposure to occupational violence - staff perceptions of 'peer' support

Mental health professionals frequently work in environments where stressful, unpredictable, and potentially volatile situations can arise. Staff responses to these, often violent events, can be severe and enduring. Psychological first aid provided by a colleague following exposure to such violence is gaining increasing acceptance as a means of assisting affected individuals. However, there has been little attention to how staff perceive this support. In this study, interviews were conducted with 13 staff employed in a secure facility and thematically analysed using content analysis. Four content themes emerged: responding to emotional distress, empowering staff through practical support, the good provider, and resilience. The results indicate that staff value and benefit from receiving support from peers following exposure to occupational violence. Most would access peer support again and would consider recommending it to others. A small number choose not to engage with the programme and the reasons for this are also discussed. This type of peer support could be applied in other high-risk workplaces as a key element of an integrated and comprehensive workplace violence prevention and management strategy.

Aggressive Behavior and Psychiatric Inpatients: a Narrative Review of the Literature with a Focus on the European Experience

PURPOSE OF REVIEW

We summarized peer-reviewed literature on aggressive episodes perpetrated by adult patients admitted to general hospital units, especially psychiatry or emergency services. We examined the main factors associated with aggressive behaviors in the hospital setting, with a special focus on the European experience.

RECENT FINDINGS

A number of variables, including individual, historical, and contextual variables, are significant risk factors for aggression among hospitalized people. Drug abuse can be considered a trans-dimensional variable which deserves particular attention. Although mental health disorders represent a significant component in the risk of aggression, there are many factors including drug abuse, past history of physically aggressive behavior, childhood abuse, social and cultural patterns, relational factors, and contextual variables that can increase the risk of overt aggressive behavior in the general hospital. This review highlights the need to undertake initiatives aimed to enhance understanding, prevention, and management of violence in general hospital settings across Europe.

Prevalence of Workplace Bullying and Its Associated Factors at a Multi-Regional Saudi Arabian Hospital: A Cross-Sectional Study

Background

Workplace bullying (WPB) refers to any form of repeated and unreasonable verbal, physical or sexual harassment that an employee endures by a person or a group. In healthcare settings, practitioners are occasionally victims of WPB incidents. The aim of this study was to survey victims of WPB and determine factors associated with being a victim of WPB at a multiregional health care facility in Saudi Arabia.

Methods

This cross-sectional study was conducted in 2018, by distributing a self-administered questionnaire via a private electronic mail to all fulltime healthcare practitioners within a multi-regional hospital in Saudi Arabia. Healthcare practitioners included physicians, nurses, allied healthcare professionals and pharmacists who reported being exposed to WPB in the past year. Study outcomes were the prevalence rate ratio of WPB and its associated factors, such as victim, perpetrator and incident characteristics.

Results

WPB has been reported by 684 participants. Perpetrators were mainly patients (36.1%), their families/relatives (29.5%), and hospital staff (27.2%) or managers/supervisors (7.2%). The type of WPB incident was mostly verbal abuse (98.1%) followed by physical harassment (11.8%) and sexual connotations (5.8%). WPB was 30% more prevalent among younger nurses and 24% less prevalent among higher educated nurses compared to their counter groups, P<0.001 each. Among technicians and administrative employees, WPB was 54% more prevalent among females, 36% more prevalent among the younger group, and 25% more prevalent among expatriate workers compared to their counter groups P<0.014, P<0.001 and P=0.017, respectively. WPB was 20% less prevalent among higher educated allied health professionals, P=0.002. Among physicians, WPB was 33% more prevalent among females, P=0.041 and was 47% more prevalent among higher educated physicians compared to their counter groups, P=0.018.

Conclusion

WPB might occur any time, anywhere and by any person within health care facilities. The prevalence of WPB varies within health occupational groups. Gender, age, educational level, and nationality were significantly associated factors with WPB.

'It comes with the territory' - Staff experience with violation and humiliation in mental health care - A mixed method study

BACKGROUND

The aim of this study was to investigate staff's experiences with violation and humiliation during work in mental health care (MHC). A total of 1160 multi-professional MHC staff in Norway responded to an online questionnaire about their experiences with different kinds of violation and humiliation in the MHC setting. In addition, a sample of professionals (eight MHC nurses) were recruited for in-depth individual interviews.

METHOD

The study used an explorative mixed method with a convergent parallel design; this included a web-based questionnaire to MHC staff in combination with individual interviews. The sample is considered to be equivalent to staff groups in MHC in Norway.

RESULTS

Between 70 and 80% of the staff reported experiencing rejection, being treated with disrespect, condescending behaviour or verbal harassment. Male workers were significantly more often victims of serious physical violence, and women were significantly more often targets for sexual harassment. In interviews, participants said they considered being exposed to violence and humiliation to be part of the job when working in MHC, and that experience, as well as social support from colleagues, helped MHC practitioners to cope better with violent situations and feel less humiliated at work.

DISCUSSION

A high amount of MHC staff report experiences of being violated and humiliated during work. The participants' perceptions of the users and their behaviour seem to influence their experience of feeling violated and humiliated. Knowledge about the dynamics of aggression between staff and users in MHC may be used in safeguarding staff and users, prevent coercion and heighten the quality of care.

Maternal Diet Influences the Reinstatement of Cocaine-Seeking Behavior and the Expression of Melanocortin-4 Receptors in Female Offspring of Rats

Recent studies have emphasized the role of the maternal diet in the development of mental disorders in offspring. Substance use disorder is a major global health and economic burden. Therefore, the search for predisposing factors for the development of this disease can contribute to reducing the health and social damage associated with addiction. In this study, we focused on the impact of the maternal diet on changes in melanocortin-4 (MC-4) receptors as well as on behavioral changes related to cocaine addiction. Rat dams consumed a high-fat diet (HFD), high-sugar diet (HSD, rich in sucrose), or mixed diet (MD) during pregnancy and lactation. Using an intravenous cocaine self-administration model, the susceptibility of female offspring to cocaine reward and cocaine-seeking propensities was evaluated. In addition, the level of MC-4 receptors in the rat brain structures related to cocaine reward and relapse was assessed. Modified maternal diets did not affect cocaine self-administration in offspring. However, the maternal HSD enhanced cocaine-seeking behavior in female offspring. In addition, we observed that the maternal HSD and MD led to increased expression of MC-4 receptors in the nucleus accumbens, while increased MC-4 receptor levels in the dorsal striatum were observed after exposure to the maternal HSD and HFD. Taken together, it can be concluded that a maternal HSD is an important factor that triggers cocaine-seeking behavior in female offspring and the expression of MC-4 receptors.