The influence of staff training on the violence prevention and management climate in psychiatric inpatient units

Violence prevention and management is an important part of inpatient psychiatric nursing and specific staff training is regarded essential. The training should be based on primary, secondary and tertiary prevention. In Stockholm, Sweden, the Bergen model is a staff-training programme that combines this preventive approach with the theoretical nursing framework of the City model that includes three staff factors: positive appreciation of patients, emotional regulation and effective structure. We evaluated this combination of the Bergen and City models on the violence prevention and management climate in psychiatric inpatient wards. A 13-item questionnaire was developed and distributed to patients and staff in 41 wards before the staff was trained and subsequently to 19 of these wards after training. Data analyses included factor analysis, Fisher's exact test and Mann-Whitney U-test. The result showed that the staff on trained wards had a more positive perception of four of the items and the patients of one item. These items reflected causes of patient aggression, ward rules, the staff's emotional regulation and early interventions. The findings suggest that a focus on three levels of prevention within a theoretical nursing framework may promote a more positive violence prevention and management climate on wards.

The bulldozer and the ballet dancer: aspects of nurses' caring approaches in acute psychiatric intensive care

Demanding conditions in acute psychiatric wards inhibit provision of safe, therapeutic care and leave nurses torn between humanistic ideals and the harsh reality of their daily work. The aim of this study was to describe nurses' caring approaches within this context. Data were collected from interviews with nurses working in acute psychiatric intensive care. Data were analysed using qualitative analysis, based on interpretive description. Results revealed a caring-approach continuum on which two approaches formed the main themes: the bulldozer and the ballet dancer. The bulldozer approach functioned as a shield of power that protected the ward from chaos. The ballet dancer approach functioned as a means of initiating relationships with patients. When examining the data from a theoretical perspective of caring and uncaring encounters in nursing, the ballet dancer approach was consistent with a caring approach, while the bulldozer approach was more complex and somewhat aligned with uncaring approaches. Conclusions drawn from the study are that although the bulldozer approach involves a risk for uncaring and harming actions, it also brings a potential for caring. This potential needs to be further explored and nurses should be encouraged to reflect on how they integrate paternalistic nursing styles with person-centred care.

Evidence and Ethics in Psychiatric Coercive Practices, A Neglected Dilemma?

Sound humanitarian psychiatry has for long, perhaps always struggled with the conflict between being therapeutical with the patients best interest at hand and the demand for restricting and applying coercive measures against the patients will and autonomy for the sake of protecting the integrity and security of not only the patient, but also her/his surroundings. This conflict includes a number of ethical issues such as preserving the patients’ autonomy, safeguarding the autonomy and security of the patients’ family as well as societal interests.

At the same time, some psychiatric research deals with the evidence of psychiatrically motivated restrictive and coercive measures and their possible therapuetic effect. Recent reviews have found that there is no evidence for the therapeutic effect of coercive measures. In view of the reasons for coercive measures, the issue of its therapeutical effects seems wrongly addressed.

It will be argued in this presentation that the issue is how psychiatry intended for the most severely disturbed patients should live up to delivering ethically sound services is a question of proper supervision. The presentation will problematise these issues as well as arguing that psychiatry intended for the most severely disturbed has to be politically controled within the frame of a democratic society with sound ethical human principles.

The prevalence and nature of intellectual disability in Norwegian prisons

BACKGROUND

The objective of the study was to calculate the prevalence of inmates with intellectual disabilities (ID), and identify historical, medical and criminological characteristics of a certain impact.

METHODS

A random sample of 143 inmates from a Norwegian prison cross sectional sample was studied. The Hayes Ability Screening Index (HASI) was validated with the Wechsler Abbreviated Scale of Intelligence (WASI).

RESULTS

The prevalence of inmates with ID, IQ < 70, was 10.8%. Some essential characteristics of inmates with ID were more frequent medication for mental disorders, a higher number of imprisonments, less drug abuse and less education than the other inmates. The results indicated that the HASI is a valid tool for screening of ID for the Norwegian inmates.

CONCLUSIONS

The prevalence of ID in Norwegian inmates is significant, measured by WASI and HASI. Identification, rehabilitation and care, concerning an intellectual handicap, are mostly absent in the Norwegian criminal justice system.

Violence from young women involuntarily admitted for severe drug abuse

OBJECTIVE

To simultaneously evaluate actuarial and dynamic predictors of severe in-patient violence among women involuntarily admitted for severe drug abuse.

METHOD

All patients admitted to special facilities for involuntary treatment of absconding-prone, previously violent, drug abusing women in Sweden were assessed with the Staff Observation Aggression Scale, revised. Actuarial data on risk factors for violence were collected and considered in an extended Cox proportional hazards model with multiple events and daily assessments of the Broset Violence Checklist as time-dependent covariates.

RESULTS

Low-grade violence and being influenced by illicit drugs were the best predictors of severe violence within 24 h. Significant differences in risk for violence between different institutions were also found.

CONCLUSION

In-patient violence risk is rapidly varying over time with being influenced by illicit drugs and exhibiting low-grade violence being significant dynamic predictors. Differences in violence between patients could not be explained by patient characteristics.

Nurses' short-term prediction of violence in acute psychiatric intensive care

OBJECTIVE

To evaluate the short-term predictive capacity of the Brøset Violence Checklist (BVC) when used by nurses in a psychiatric intensive care unit.

METHOD

Seventy-three patients were assessed according to the BVC three times daily. Violent incidents were recorded with the Staff Observation Aggression Scale, revised version. An extended Cox proportional hazards model with multiple events and time-dependent covariates was estimated to evaluate how the highest BVC sum of the last 24 h and its separate items affect the risk for severe violence within the next 24 h.

RESULTS

With a BVC sum of one or more, hazard for severe violence was six times higher than if the sum was zero. Four of the six separate items significantly increased the risk for severe violence with hazard ratios between 3.0 and 6.3.

CONCLUSION

Risk for in-patient violence in a short-term perspective can to a high degree be predicted by nurses using the BVC.

Measuring aggression with the staff observation aggression scale--revised

OBJECTIVE

The staff observation aggression scale (SOAS; Palmstierna & Wistedt, 1987) was developed to measure nature, number, as well as severity of aggressive incidents. In 1999, a revised version of the SOAS (i.e. the SOAS-R), with a more fine-grained severity scoring system, was presented. In the current paper, the development and testing of the revised severity scores of the SOAS-R are addressed.

METHOD

In two consecutive studies, staff members recorded inpatient aggression on SOAS-R forms, but also expressed their opinion about the severity of incidents on 100 mm visual analogue scales (VASs). Correlations were calculated between SOAS and SOAS-R severity scores, on the one hand, and clinical judgements of severity, on the other.

RESULTS

In both studies, revised SOAS severity scores were more closely related to clinical judgements of aggression severity than the original ones.

CONCLUSION

The SOAS-R is a promising tool for research on the prevalence, severity and determinants of inpatient aggression.

Issues in the measurement of violent incidents and the introduction of a new scale: the 'attacks' (attempted and actual assault scale)

OBJECTIVE

To review the strengths and weaknesses of existing violent incident measures, and introduce a new scale, the 'attacks'. The new scale provides an objective measure of incident severity and focuses on interpersonal physical violence in isolation from other behaviours.

METHOD

The new scale was piloted on six psychiatric wards in the East End of London over a period of 16 weeks. Descriptive data were obtained and validated against official violent incident records.

RESULTS

There were 40 incidents by 21 aggressive patients, most of which occurred on the psychiatric intensive care unit. Striking assaults predominated. Continuous holding of the patient by nurses occurred after 17% of incidents. Special observation was also used as a subsequent management method in more than half of the incidents.

CONCLUSION

The scale is acceptable to nurses and valid. Interesting questions are raised about the content of training for staff in the prevention and management of violent incidents.

Fifteen years of research with the Staff Observation Aggression Scale: a review

OBJECTIVE

Research on the prevalence and causes of in-patient aggression has been hindered by the use of different methods for measuring aggression. Since Palmstierna and Wistedt presented the Staff Observation Aggression Scale (SOAS) in 1987, this data collection method has been used in various studies, which may make comparisons more useful.

METHOD

Studies with SOAS aggression data were compiled using MEDLINE, the Internet, and references from SOAS papers.

RESULTS

Reviews of studies on psychometric properties suggest fair to good inter-rater reliability and validity for SOAS assessments. The number of aggressive incidents per patient per year found on acute admissions wards (n = 38) considerably varied, with a range of 0.4-33.2 incidents (mean = 9.3).

CONCLUSION

Although the aggression data included in the present review were obtained in highly comparable ways, substantial differences in aggression rates between wards were still found. Some countries (e.g. the Netherlands) appear to have a relatively high incidence of aggression on acute wards.

Prediction of aggression on a locked psychiatric admissions ward

OBJECTIVE

The present study evaluates the accuracy of clinical and archival predictors of patients' aggressive behaviour on a locked admissions ward.

METHOD

Over a 9-month period, staff members estimated the likelihood that patients would become aggressive during their stay in the ward. These unaided clinical assessments were obtained with Visual Analogue Scales (VASs) administered before the end of the first full day of admission. Archival predictions were based on demographic variables (e.g. gender, number of previous admissions, diagnosis) derived from patients' admission forms. Aggressive behaviour was recorded with the Staff Observation Aggression Scale-Revised (SOAS-R).

RESULTS

Clinical predictions of aggression were found to be moderately accurate. On the basis of clinical estimates, 75% of the patients were correctly classified as becoming aggressive or not.

CONCLUSION

Although a body of evidence indicates that unaided clinical prediction of violent recidivism after hospital discharge does not perform well, it may be quite accurate in estimating short-term aggression risks during acute psychiatric admission.

A model for predicting alcohol withdrawal delirium

OBJECTIVE

The aim of this study was to develop a model for identifying patients with a high risk of developing alcohol withdrawal delirium after assessment in the emergency department.

METHODS

Patients seeking acute treatment for alcohol withdrawal at St. Göran's hospital in Stockholm were evaluated for known risk factors for alcohol withdrawal delirium. All patients with any risk factor were admitted to the hospital and received standard treatment with benzodiazepines. All patients were evaluated at admission by the physician in charge at the psychiatric and dependency emergency unit at the hospital. Treatment and final assessment were conducted at the unit's inpatient acute-treatment facility. Correlations were determined between risk factors noted at admission and development of alcohol withdrawal delirium, as defined in DSM-IV, after admission. A total of 334 alcohol-dependent patients were included in the study.

RESULTS

Twenty-three patients, or 6.9 percent, developed alcohol withdrawal delirium after admission despite benzodiazepine treatment. In a stepwise multiple regression model, five risk factors were significantly correlated with the development of alcohol withdrawal delirium: current infectious disease; tachycardia, defined as a heart rate above 120 beats per minute at admission; signs of alcohol withdrawal accompanied by an alcohol concentration of more than 1 gram per liter of body fluid; a history of epileptic seizures; and a history of delirious episodes. No patient without these five risk factors developed delirium.

CONCLUSION

Assessment for five easily detectable risk factors can enable the clinician to make an accurate and quantitative assessment of a patient's risk of developing alcohol withdrawal delirium.

[Drug addicts with severe mental disorders can be helped by programs using moderate means. Good results when psychiatric, social and drug abuse services cooperate]

Dependency disorders are more common than expected in psychiatric populations. Untreated, dual diagnosis leads to severe social and psychiatric deterioration. Nine treatment resistant, homeless, drug addicts suffering from chronic psychotic disorders were selected to take part in a case management program, integrating social services with regular psychiatric treatment. All but one were greatly improved in general terms as well as regarding their ability to maintain an ordered life style. The need for institutional care decreased dramatically.

Ethical benefits and costs of coercion in short-term inpatient psychiatric care

OBJECTIVE

The study examined the outcome of psychiatric inpatient care in terms of patients' reports of ethical benefits, which were defined as fulfillment of the ethical principles of beneficence and autonomy, and ethical costs, which were defined as any violation of those principles.

METHODS

A consecutive sample of 84 committed patients and a random sample of 84 voluntarily admitted patients in psychiatric care in two Swedish counties were studied. The patients were assessed twice by a psychiatrist, at admission and at discharge or after three weeks of care. They were also interviewed by a clinical psychologist at discharge or after three weeks. Four aspects of the ethical benefits or costs of their care were examined--whether they reported improvement in mental health, being treated with respect, not being violated as a person, and not being exposed to measures against their will (aside from commitment).

RESULTS

The great majority of all patients reported improvement as a result of the psychiatric care. A third of the committed patients and more than half of the voluntarily admitted patients experienced ethical benefits only, without ethical costs. Twenty-three percent of the committed patients and 13 percent of the voluntary patients experienced ethical costs only, without ethical benefits. Some of the patients who experienced ethical costs only were also rated by a psychiatrist as not improved.

CONCLUSIONS

Few patients had no measurable benefits of care. For committed as well as voluntary patients, an association was found between perceived respect for autonomy and self-reported improvement in mental health.

Changes in the pattern of aggressive behaviour among inpatients with changed ward organization

Aggressive behaviour by psychiatric inpatients was investigated on the same ward during two separate 6-month periods before and after a 50% decrease in number of beds but without changes in catchment area. Character of the patient group, patient turnover and medical practices as well as total number of staff on duty on the ward was virtually the same during the two periods. It is therefore assumed that differences in aggressive behaviour are mainly explained by effects due to the decreased number of beds per se. It was found that the 50% reduction did not affect the overall aggression frequency. However, inter-patient violence increased while the number of more severe aggressive incidents towards staff members decreased.

The relationship of crowding and aggressive behavior on a psychiatric intensive care unit

During a 25-week period, all incidents of aggressive behavior in a 19-bed psychiatric acute care unit were systematically recorded using the Staff Observation Aggression Scale. Forty-seven of the 163 patients admitted to the unit were aggressive on 119 occasions. Of these incidents, 100 were physical attacks on another person, and 95 were perpetrated by 23 patients. The patients were predominantly aggressive without visible provocation or were provoked by staff's denying a request. An increased number of patients on the ward significantly increased the likelihood of aggressive behavior, especially by patients with schizophrenia or schizophreniform disorder.

Risk factors for aggressive behaviour are of limited value in predicting the violent behaviour of acute involuntarily admitted patients

Violent behaviour within 8 and 28 days respectively was related by a multivariate statistical procedure to risk factors for aggressive behaviour in an epidemiologically representative sample of 105 acute involuntarily admitted patients. Previous violent behaviour by the patient was found to correlate significantly with aggressive behaviour during the first 8 days of admission, and abuse of drugs other than alcohol was found to correlate significantly with aggressive behaviour during the first 28 days of admission. Determination coefficients were very low, and it is concluded that risk factors associated with aggressive behaviour are of limited value in predicting aggressive behaviour among acute involuntarily admitted inpatients.

Evaluation of the Brief Psychopathological Rating Scale in relation to aggressive behavior by acute involuntarily admitted patients

Aggressive behavior during acute involuntary admission was related to ratings on the Brief Psychopathological Rating Scale, age, sex and global assessment in 38 patients. The best prediction model of aggressive behavior was achieved when predicting more serious incidents occurring during the first 8 days of admission. In this prediction model, high scores of hostility and anxiety, together with low scores of grandiosity significantly and accurately predicted more serious violent behavior.

Aggressive behavior in hospitalized psychogeriatric patients

The frequency and characteristics of aggressive and hostile behavior in 40 psychogeriatric inpatients was investigated using the Staff Observation Aggression Scale (SOAS). Most aggressive acts were directed towards nursing staff when providing help with activities of daily living. A positive correlation was found between age and the frequency of aggressive behavior, while severity was most strongly correlated to length of admission. A significant decrease in frequency was observed during the six weeks of observation. The causes of this decrease are discussed together with the implications for future studies on the treatment of aggressive behavior in this group of patients.

Prevalence of risk factors for aggressive behavior: characteristics of an involuntarily admitted population

In Västmanland County, Sweden, 105 patients were acute admitted and involuntarily treated during a six-month period. In spite of a low mean age (39.2 years), abuse of alcohol or other drugs was common (29%). Thirty-nine percent of the patients showed violent behavior prior to the actual admission and 36% of the patients had shown such behavior prior to earlier admissions. Of the patients below 40 years, 32% had a disability pension.

Staff observation aggression scale, SOAS: presentation and evaluation

A new psychiatric report and rating scale assessing severity and frequency of aggressive behaviour is presented and evaluated. It is based on the staff's standardized reports of aggressive incidents. By using a special aggression report form, comprehensive and standardized information is obtained, thereby permitting scoring and further analysis of different aspects of aggressive incidents. The reliability of scoring is tested and found to be good as is the scale's capacity to discriminate between different patterns of aggressive behaviour in different groups of patients. As a result of this and because of the simplicity of the scale, it is thought to be a potentially useful tool in scientific research on aggressive behaviour from psychiatric inpatients.

Absence of acquired tolerance to neuroleptics in schizophrenic patients

Development of increased tolerance to neuroleptics was investigated in 38 neuroleptic-respondent schizophrenic patients. At 5- or 8-year follow-up, clinical global assessments were related to changes in neuroleptic doses. In 93% of the patients gradually increasing tolerance could be excluded.

Depressive symptoms in chronic schizophrenic patients after withdrawal of long-acting neuroleptics

A double-blind randomized investigation compared withdrawal (placebo) with continued use of long-acting neuroleptics (fluphenazine decanoate or flupenthixol decanoate) in 41 chronic schizophrenic outpatients. After 6 weeks there was a tendency toward higher depressive scores in the placebo group, a difference which became statistically significant (p less than .05) at week 24. These results do not support earlier observations that neuroleptic drugs cause depression. Further analyses of the data indicated that depressive symptomatology could be an early sign of relapse.