Identification of the "minimal triangle" and other common event-to-event transitions in conflict and containment incidents

Psychosocial Problems among Psychiatric Nurses for Caring Patients with Mental Disorders during the COVID-19 Pandemic

COVID-19 has a negative effect on the psychological well-being of psychiatric nurses. Thus, examining the psychosocial response of nurses is important for preventing more serious mental health problems and disruption of the quality of nursing care. This study aimed to evaluate the psychosocial problems of nurses who provided nursing care to patients with mental health disorders during the COVID-19 pandemic. A quantitative study with a cross-sectional design was conducted. The 101 nurses at Central Mental Health Hospital who provide nursing care to patients with mental health disorders were recruited through consecutive sampling. The instruments used were the demographic questionnaire, the Expanded Nursing Stress Scale, Zung Self-Rating Anxiety Scale, and The Connor-Davidson Resilience Scale 25. Univariate and bivariate analyses were used to process the data. The mean score of 45.1 (±24.3) was obtained for the ENSS; around 97% of nurses have a work stress score below the average, 4.95% have mild-moderate anxiety, and 28.7% have a low level of resilience. Work stress and contact frequency, work stress and gender, anxiety and contact frequency, as well as resilience and contact frequency all correlated significantly (p value <0.05). The Pearson test showed a significant positive correlation between work stress and anxiety (p: 0.002, r: 0.299). However, there was no significant correlation between anxiety and resilience (p: 0.643, r: 0.47), nor between work stress and resilience (p: 0.643; r: 0.47). Psychosocial disorders that psychiatric nurses face include occupational stress, mild-moderate anxiety, and low resilience. The government can create specific infection control guidelines for the mental health setting, and hospital management or ward leaders can also provide support to psychiatric nurses to increase resilience in reducing psychosocial problems.

De-escalation of conflict in forensic mental health inpatient settings: a Theoretical Domains Framework-informed qualitative investigation of staff and patient perspectives

Background

Violence and other harms that result from conflict in forensic inpatient mental health settings are an international problem. De-escalation approaches for reducing conflict are recommended, yet the evidence-base for their use is limited. For the first time, the present study uses implementation science and behaviour change approaches to identify the specific organisational and individual behaviour change targets for enhanced de-escalation in low and medium secure forensic inpatient settings. The primary objective of this study was to identify and describe individual professional, cultural and system-level barriers and enablers to the implementation of de-escalation in forensic mental health inpatient settings. The secondary objective was to identify the changes in capabilities, opportunities and motivations required to enhance de-escalation behaviours in these settings.

Methods

Qualitative design with data collection and analysis informed by the Theoretical Domains Framework (TDF). Two medium secure forensic mental health inpatient wards and one low secure mental health inpatient ward participated. 12 inpatients and 18 staff participated across five focus groups and one individual interview (at participant preference) guided by a semi-structured interview schedule informed by the TDF domains. Data were analysed via Framework Analysis, organised into the 14 TDF domains then coded inductively within each domain.

Results

The capabilities required to enhance de-escalation comprised relationship-building, emotional regulation and improved understanding of patients. Staff opportunities for de-escalation are limited by shared beliefs within nursing teams stigmatising therapeutic intimacy in nurse-patient relationships and emotional vulnerability in staff. These beliefs may be modified by ward manager role-modelling. Increased opportunity for de-escalation may be created by increasing service user involvement in antipsychotic prescribing and modifications to the physical environment (sensory rooms and limiting restrictions on patient access to ward spaces). Staff motivation to engage in de-escalation may be increased through reducing perceptions of patient dangerousness via post-incident debriefing and advanced de-escalation planning.

Conclusions

Interventions to enhance de-escalation in forensic mental health settings should enhance ward staff’s understanding of patients and modify beliefs about therapeutic boundaries which limit the quality of staff-patient relationships. The complex interactions within the capabilities-opportunities-motivation configuration our novel analysis generated, indicates that de-escalation behaviour is unlikely to be changed through knowledge and skills-based training alone. De-escalation training should be implemented with adjunct interventions targeting: collaborative antipsychotic prescribing; debriefing and de-escalation planning; modifications to the physical environment; and ward manager role-modelling of emotional vulnerability and therapeutic intimacy in nurse-patient relationships.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-022-00735-6.

Aggression on the psychiatric ward: Prevalence and risk factors. A systematic review of the literature

INTRODUCTION

On psychiatric wards, aggressive behaviour displayed by patients is common and problematic. Understanding factors associated with the development of aggression offers possibilities for prevention and targeted interventions. This review discusses factors that contribute to the development of aggression on psychiatric wards.

METHOD

In Pubmed and Embase, a search was performed aimed at: prevalence data, ward characteristics, patient and staff factors that are associated with aggressive behaviour and from this search 146 studies were included.

RESULTS

The prevalence of aggressive behaviour on psychiatric wards varied (8-76%). Explanatory factors of aggressive behaviour were subdivided into patient, staff and ward factors. Patient risk factors were diagnosis of psychotic disorder or bipolar disorder, substance abuse, a history of aggression, younger age. Staff risk factors included male gender, unqualified or temporary staff, job strain, dissatisfaction with the job or management, burn-out and quality of the interaction between patients and staff. Staff protective factors were a good functioning team, good leadership and being involved in treatment decisions. Significant ward risk factors were a higher bed occupancy, busy places on the ward, walking rounds, an unsafe environment, a restrictive environment, lack of structure in the day, smoking and lack of privacy.

CONCLUSION

Despite a lack of prospective quantitative data, results did show that aggression arises from a combination of patient factors, staff factors and ward factors. Patient factors were studied most often, however, besides treatment, offering the least possibilities in prevention of aggression development. Future studies should focus more on the earlier stages of aggression such as agitation and on factors that are better suited for preventing aggression such as ward and staff factors. Management and clinicians could adapt staffing and ward in line with these results.

How has COVID-19 affected mental health nurses and the delivery of mental health nursing care in the UK? Results of a mixed-methods study

WHAT IS KNOWN ON THE SUBJECT?: During the COVID-19 pandemic, there has been research considering the impact on medical healthcare professionals and the mental health needs of the general population. However, limited focus has been placed on mental health services or mental health staff providing care in the community and in hospitals. While nurses make up the largest section of the mental health workforce in the UK, the impact that this pandemic has had on their work has been largely ignored. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This paper provides a unique insight into the experiences and impact that the COVID-19 pandemic has had on mental health nurses across a range of community and inpatient settings to understand what has changed in their work and the care they can and do provide during this crisis. This includes exploring how services have changed, the move to remote working, the impact of the protective equipment crisis on nurses and the difficult working conditions facing those in inpatient settings where there is minimal guidance provided. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: By understanding the impact the pandemic has had on mental health nursing care, we can understand the gaps in guidance that exist, the challenges being faced and the impact the crisis has had on care for mental health service users. By doing so, we can plan for the ongoing nature of this pandemic and the aftermath that the crisis may leave for our service users and workforce alike. ABSTRACT: Introduction While evidence has emerged concerning the impact of COVID-19 on the general population and the challenges facing health services, much less is known regarding how the pandemic has directly affected the delivery of mental health nursing care. Aim This paper aimed to explore how COVID-19 has affected the ability of mental health nurses to deliver care in community and inpatient mental health services in the UK. Method We investigated staff reports regarding the impact of the COVID-19 pandemic on mental healthcare and mental health service users in the UK, using a mixed-methods online survey. A total of 897 nurses across a range of inpatient and community settings participated. Discussion Key themes within the data explore the following: new ways of working; remote working; risks of infection/infection control challenges; and the impact on service users. Targeted guidelines are required to support mental health nurses providing care and support during a pandemic to people in severe mental distress, often in unsuitable environments. Implications for Practice Service developments need to occur alongside tailored guidance and support for staff welfare supported by clear leadership. These findings identify areas requiring attention and investment to prepare for future crises and the consequences of the pandemic.

Worker and perceived team climate factors influence the use of restraint and seclusion in youth residential treatment centers: Results from a mixed-method longitudinal study

BACKGROUND

Restraint and seclusion (R&S) are controversial methods of intervention aimed at protecting children from immediate harm in residential treatment centers (RTC). Previous studies have mainly focused on situational factors and youth characteristics to predict its use.

OBJECTIVES

This study sought to evaluate the role other potential predictors could play in the decision to use R&S, namely characteristics of residential workers and their perceived team climate.

METHODS

For two months, a total of 132 residential workers from different RTC in the greater Montreal area completed weekly diaries of standardized questionnaires. Using an explanatory sequential design (i.e., mixed methods), this study aimed at exploring the role of residential workers' characteristics (e.g., exposure to client aggression, stress and fatigue) and aspects of their perceived team climate (e.g., order and organization, communication and openness) as predictors of R&S use. Survey results were later also presented to four focus groups for discussion.

RESULTS

Results indicated that exposure to verbal violence from youths was associated with the increased use of R&S. Meanwhile, perceived communication and openness were associated with lower rates of R&S use. Participants shared that repeated exposure to verbal violence diminished their level of tolerance while teamwork provided them with the emotional space needed to focus on the needs of youths and find alternatives to R&S.

CONCLUSION

This study sheds light on the complex role of human emotions in the decision to use of R&S. Specifically, intense momentary emotions during crisis interventions had a greater influence on the use R&S than chronic states, such as fatigue.

Prevalence of the use of chemical restraint in the management of challenging behaviours associated with adult mental health conditions: A meta-synthesis

WHAT IS KNOWN ON THE SUBJECT?: The use of chemical restraint in emergency situations is to control aggression or violence to protect consumers and staff and is to be used as a last resort when all other behavioural control alternatives have been exhausted. Chemical restraint involves the use of medication. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This is the first paper to systematically review the prevalence of the use of chemical restraint. The use of chemical restraint is common across emergency departments and acute psychiatric inpatient units worldwide. Consumers who are restrained are also likely to receive chemical restraint. The studies reviewed demonstrate that there is a need for more standardized data collection so that clearer comparisons can be made between healthcare settings and countries. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Implications of practice include the need to report adverse events post-chemical restraint as these can deleteriously affect a person's physical health. Identification of and staff education about first-line management techniques before chemical restraint is administered are significant to reduce its use. ABSTRACT: Introduction Chemical restraint is used to manage uncontrolled aggression, agitation or violent behaviours of consumers with mental health disorders admitted to acute psychiatric or emergency settings. Aim This systematic review aimed to synthesize the international prevalence of chemical restraint for non-consenting adults. Method PsycINFO, CINAHL, MEDLINE/PubMed and Google Scholar databases were searched for peer-reviewed literature published between January 1996 and July 2018. This paper reports on data extracted from retrospective audits of chemical restraint practice. Results Forty-eight papers were included. The median prevalence of use of any restraint was 21.2% (25th% 8.0 to 75th% 36.3). Median prevalence of people who were chemically restrained, of all people restrained in any manner, was 43.1% (25th% 22.9% to 75th% 70.7%). Of all people admitted to facility(ies), the median prevalence of chemical restraint was 7.4% (25th% 2.7 to 75th% 17.6). There was no statistically significant difference in any prevalence measure considering healthcare setting or country. There was a significant decrease over the review period in the use of any restraint, including chemical restraint. Discussion and implications for practice This is the first known comprehensive meta-view of chemical restraint use worldwide, highlighting the need for standardized data collection to enable comparisons between healthcare settings and countries. Relevance statement There is an international imperative to reduce or eliminate the use of coercive practices, such as physical and chemical restraint, in mental health care. This study provides important information for mental health nursing by synthesizing the international prevalence of chemical restraint for non-consenting adults. This meta-view of the worldwide use of chemical restraint can inform ongoing efforts to reduce its use.

International research into 22 years of use of chemical restraint: An evidence overview

BACKGROUND

Chemical restraint (CR) (also known as rapid tranquilisation) is the forced (non-consenting) administration of medications to manage uncontrolled aggression, anxiety, or violence in people who are likely to cause harm to themselves or others. Our population of interest was adults with mental health disorders (with/without substance abuse). There has been a growing international movement over the past 22 years towards reducing/eliminating restrictive practices such as CR. It is appropriate to summarise the research that has been published over this time, identify trends and gaps in knowledge, and highlight areas for new research to inform practice.

AIMS

To undertake a comprehensive systematic search to identify, and describe, the volume and nature of primary international research into CR published since 1995.

METHODS

This paper reports the processes and overall findings of a systematic search for all available primary research on CR published between 1 January 1996 and 31 July 2018. It describes the current evidence base by hierarchy of evidence, country (ies) producing the research, CR definitions, study purpose, and outcome measures.

RESULTS

This review identified 311 relevant primary studies (21 RCTs; 46 non-controlled experimental or prospective observational studies; 77 cross-sectional studies; 69 retrospective studies; 67 opinion pieces, position or policy statements; and 31 qualitative studies). The USA, UK, and Australia contributed over half the research, whilst cross-country collaborations comprised 6% of it. The most common research settings comprised acute psychiatric wards (23.3%), general psychiatric wards (21.6%), and general hospital emergency departments (19.0%).

DISCUSSION

A key lesson learnt whilst compiling this database of research into CR was to ensure that all papers described non-consenting administration of medications to manage adults with uncontrolled aggression, anxiety, or violence. There were tensions in the literature between using effective CR without producing adverse events, and how to decide when CR was needed (compared with choosing non-chemical intervention for behavioural emergencies), respecting patients' dignity whilst safeguarding their safety, and preserving safe workplaces for staff, and care environments for other patients. The range of outcome measures suggests opportunities to standardise future research.

Development and reliability testing of the Scale for the Evaluation of Staff-Patient Interactions in Progress Notes (SESPI): An assessment instrument of mental health nursing documentation

AIM

To develop and test the reliability of the Scale for the Evaluation of Staff-Patient Interactions in Progress Notes (SESPI). Therapeutic nurse-patient interactions are fundamental in mental health nursing. However, little is known about how these interactions are recorded in nursing documentation and there is no instrument available for collecting this type of information for quantitative analysis.

DESIGN

Instrument development and reliability testing.

METHODS

The development of the SESPI was based on qualitative analyses of progress notes retrieved from patient records in two mental health services. A self psychological attunement perspective guided the analyses. SESPI was tested for internal consistency and inter-rater reliability after 22 nurses independently scored 10 progress notes.

RESULTS

Cronbach's alpha for the entire instrument was 0.977, indicating that the raters' scores had very high internal consistency. ICC was 0.770. The alpha and ICC values for each step were high, varying between 0.970 and 0.992.

De-escalating Angry Caregivers: A Randomized Controlled Trial of a Novel Communication Curriculum for Pediatric Residents

OBJECTIVE

Medical providers struggle when communicating with angry patients and their caregivers. Pediatric residents perceive communication competencies as an important priority for learning, yet they lack confidence and desire more training in communicating with angry families. Few curricula exist to support trainees with de-escalation skill development. We developed, implemented, and evaluated the impact of a novel de-escalation curriculum on pediatric resident communication skills.

METHODS

We conducted a randomized controlled trial of a 90-minute de-escalation curriculum for pediatric residents from August to September 2016. Trained standardized patient (SP) actors rated residents' communication skills following 2 unique encounters before and after the intervention or control sessions. Residents completed a retrospective pre/post communication skills self-assessment and curriculum evaluation. We used independent and paired t-tests to assess for communication improvements.

RESULTS

Eighty-four of 88 (95%) eligible residents participated (43 intervention, 41 control). Residents reported frequent encounters with angry caregivers. At baseline, interns had significantly lower mean SP-rated de-escalation skills than other residents (P = .03). Intervention residents did not improve significantly more than controls on their pre/post change in mean SP-rated de-escalation skills; however, intervention residents improved significantly on their pre/post mean self-assessed de-escalation skills (P ≤ .03).

CONCLUSIONS

Despite significant self-assessed improvements, residents' SP-rated de-escalation skills did not improve following a skills-based intervention. Nevertheless, our study illustrates the need for de-escalation curricula focused on strategies and peer discussion, suggests optimal timing of delivery during fall of intern year, and offers an assessment tool for exploration in future studies.

Patient perspectives on barriers and enablers to the use and effectiveness of de-escalation techniques for the management of violence and aggression in mental health settings

AIM

Investigate patient perspectives on barriers and enablers to the use and effectiveness of de-escalation techniques for aggression in mental health settings.

BACKGROUND

De-escalation techniques are the recommended first-line intervention for the management of aggression in mental health settings internationally, yet use of higher risk restrictive practices persists. This indicates de-escalation techniques are not used at optimum frequency and/or there are important factors limiting their use and effect.

DESIGN

Descriptive qualitative research using semi-structured interviews and Framework Analysis.

METHODS

Inpatient interviews (N = 26) exploring staff, patient and environmental factors influencing the use and effectiveness of staff de-escalation were conducted mid-2014. Three service user researchers led analysis.

RESULTS

Data were synthesized in three deductive themes relating to staff, patient and environmental influences on the use and effectiveness of de-escalation techniques. The dominant view was that restrictive practices, rather than de-escalation techniques, are used in response to escalating patient behaviour. Under-use of de-escalation techniques was attributed to: lack of staff reflection on culture and practice and a need to retain control/dominance over patients. Ward rules, patient factors and a lack of staff respect for patients diluted their effectiveness. Participants identified a systematic process of de-escalation, rule subversion, reduced social distance and staff authenticity as enablers of effective de-escalation.

CONCLUSION

This study investigated patient perspectives on staff, patient and environmental influences on the use and effectiveness of de-escalation techniques. Our framework of barriers and enablers provides indicators of organizational/behaviour change targets for interventions seeking to reduce violence and restrictive practices through enhanced de-escalation techniques.

Outcomes of the Victorian Safewards trial in 13 wards: Impact on seclusion rates and fidelity measurement

Restrictive practices are used in response to conflict and aggression in psychiatric inpatient settings. Reducing such practices is the focus internationally of policy and legislative change, many initiatives, and a growing body of research. Safewards is a model and a set of 10 interventions designed to reduce conflict and containment in inpatient services. In the current study, we aimed to assess the impact of implementing Safewards on seclusion in Victorian inpatient mental health services in Australia. The study used a before-and-after design, with a comparison group matched for service type. Thirteen wards opted into a 12-week trial to implement Safewards and 1-year follow up. The comparison group was all other wards (n = 31) with seclusion facilities in the jurisdiction, matched to service type. Mandatorily-reported seclusion event data for all 44 wards over a 15-month period were analysed using negative binomial regression. Adherence to Safewards was measured via fidelity checklists at four time points: twice during the trial, post-trial, and at 1-year follow up. Seclusion rates were reduced by 36% in Safewards trial wards by the 12-month follow-up period (incidence rate ratios (IRR) = 0.64,) but in the comparison wards seclusion rates did not differ from baseline to post-trial (IRR = 1.17) or to follow-up period (IRR = 1.35). Fidelity analysis revealed a trajectory of increased use of Safewards interventions after the trial phase to follow up. The findings suggest that Safewards is appropriate for practice change in Victorian inpatient mental health services more broadly than adult acute wards, and is effective in reducing the use of seclusion.

Improving Awareness of an Acute Psychiatric Unit's Capacity for Admission

New admissions to psychiatric inpatient units can significantly impact the environment and level of safety. Maintaining safety is a core and critical responsibility of nursing, but nurses are often overlooked in the decision to admit a patient. Missed opportunities for dialogue between nurses and the admitting physician challenge nurses' ability to proactively manage the therapeutic environment. When nurses are limited in this ability, the outcome can be an unpredictable and unstable milieu. In a 25-bed acute psychiatric inpatient unit, a formalized communication system among the multidisciplinary admission team was developed. Data collected over 1 year demonstrated improved safety. Increasing the admitting provider's awareness of the current unit acuity and involving the nursing staff early in the admission process improved collaboration among care team members and reduced risks to maintaining milieu safety.

De-escalation: A survey of clinical staff in a secure mental health inpatient service

De-escalation is an important tool for preventing aggression in inpatient settings but definitions vary and there is no clear practice guideline. We aimed to identify how clinical staff define and conceptualize de-escalation, which de-escalation interventions they would use in aggressive scenarios, and their beliefs about the efficacy of de-escalation interventions. A questionnaire survey (n = 72) was conducted using open and closed questions; additionally, clinical vignettes describing conflict events were presented for participants to describe their likely clinical response. Qualitative data were subject to thematic analysis. The major themes that de-escalation encompassed were communication, tactics, de-escalator qualities, assessment and risk, getting help, and containment measures. Different types of aggression were met with different interventions. Half of participants erroneously identified p.r.n. medication as a de-escalation intervention, and 15% wrongly stated that seclusion, restraint, and emergency i.m. medication could be de-escalation interventions. Those interventions seen as most effective were the most commonly used. Clinical staff's views about de-escalation, and their de-escalation practice, may differ from optimal practice. Use of containment measures and p.r.n. medication where de-escalation is more appropriate could have a negative impact; work is needed to promote understanding and use of appropriate de-escalation interventions based on a clear guideline.

Learning and performance outcomes of mental health staff training in de-escalation techniques for the management of violence and aggression

BACKGROUND

De-escalation techniques are a recommended non-physical intervention for the management of violence and aggression in mental health. Although taught as part of mandatory training for all National Health Service (NHS) mental health staff, there remains a lack of clarity around training effectiveness.

AIMS

To conduct a systematic review of the learning, performance and clinical safety outcomes of de-escalation techniques training.

METHOD

The review process involved a systematic literature search of 20 electronic databases, eligibility screening of results, data extraction, quality appraisal and data synthesis.

RESULTS

A total of 38 relevant studies were identified. The strongest impact of training appears to be on de-escalation-related knowledge, confidence to manage aggression and deescalation performance (although limited to artificial training scenarios). No strong conclusions could be drawn about the impact of training on assaults, injuries, containment and organisational outcomes owing to the low quality of evidence and conflicting results.

CONCLUSIONS

It is assumed that de-escalation techniques training will improve staff's ability to de-escalate violent and aggressive behaviour and improve safety in practice. There is currently limited evidence that this training has these effects.

Engagement as an Element of Safe Inpatient Psychiatric Environments

BACKGROUND

The American Psychiatric Nurses Association (APNA) Institute for Safe Environments (ISE) has focused on key elements that affect safety in psychiatric treatment environments; one of these key elements is patient engagement. An ISE workgroup discussed and reviewed the literature on engagement and safety in inpatient psychiatric settings. This article presents what we have learned about the role that engagement plays in inpatient treatment of severely mentally ill individuals and evidence that links nurse-patient engagement to safety.

OBJECTIVES

To describe, using supporting literature, the role that nurse-patient engagement plays in creating safe, therapeutic environments for individuals with severe mental illness.

DESIGN

(1) Define engagement and describe why it is an important element of safe treatment environments; (2) identify what helps and what hinders patients in their engagement with nurses, and nurses in their engagement with patients; (3) describe how engagement may improve unit safety; and (4) propose recommendations and set future directions for practice, research, and education.

CONCLUSION

Engagement may provide the foundation for safe, therapeutic, and recovery-oriented treatment. In the future, APNA's ISE plans to build upon this foundation by developing a clinical model of nurse-patient engagement and safety by drawing together emerging research and practice models.

Age structure at diagnosis affects aggression in a psychiatric inpatient population: age structure affecting inpatient aggression

Study of inpatient aggression in psychiatric inpatient units (PIUs), where vulnerable patients interact intensely in small groups, is hampered by a lack of systematic monitoring of aggressive events in the context of group dynamics. Our current study examines the relationship between aggression and group structure in the PIU of a general tertiary-care hospital over a 9-month period. The severity of aggression was monitored daily using the Overt Aggression Scale (OAS). Clinical data including the daily number and mean age of subpopulations with different diagnoses were acquired. Cross-correlation function and autoregressive integrated moving average modeling were used to assess the effects of various group structure parameters on the incidence of aggressive events in the PIU. The daily total OAS score correlated positively with the daily mean age of patients with schizophrenia and bipolar disorder. By contrast, the OAS total score demonstrated a negative correlation with the daily mean age of patients with major depression. The age of the patients at diagnosis is an important group structure that affects the incidence of aggression in a PIU.