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How can we reduce violence and aggression in psychiatric inpatient units?

ABSTRACT: The inpatient environments in psychiatric units are not always conducive to patients' recovery. Male patients can easily feel bored especially when they are not interested in indoor activities like arts and crafts. Outdoor activities were little explored in our psychiatric intensive care unit and partly this may reflect a 'risk averse' approach. Like a pressure cooker, the patients' anger and frustration build up and unfortunately they may lash out on staff and other patients placing them at risk. The incidents of violence and aggression in our unit rose to 482 in 2011. The Blackpool zoo was close to our unit and it was felt that our patients may benefit a weekly trip to the zoo. Other activities like computer and gym sessions were maintained. Although there were initial reluctance and anxiety amongst staff to escort patients outside the unit, regular support and encouragement made them more confident and less risk averse. Our patients provided lots of positive feedback and felt better equipped to 'fit in' with their community after discharge. The initial discrimination against our patients at the zoo slowly transformed into partnership working and the authorities at the zoo have offered a training programme for our patients on animal care and hygiene. Over a period of 12 months, the incidence of aggression and violence in the ward reduced to 126. The average length of stay reduced by about 50%. We also discharged patients who recovered remarkably well, directly from the unit rather than stepping down to acute wards. Staff motivation and enthusiasm continued to improve and this was reflected in the reduction in staff sickness rates by more than 50%. Student nurses and doctors were able to understand the positive aspects of patients' lives and skills and felt able to boost their hope and determination.

SUBMITTER: Antonysamy A

PROVIDER: S-EPMC4652698 | biostudies-literature | 2013

REPOSITORIES: biostudies-literature

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How can we reduce violence and aggression in psychiatric inpatient units?

Antonysamy Arokia A

BMJ quality improvement reports 20130605 1

The inpatient environments in psychiatric units are not always conducive to patients' recovery. Male patients can easily feel bored especially when they are not interested in indoor activities like arts and crafts. Outdoor activities were little explored in our psychiatric intensive care unit and partly this may reflect a 'risk averse' approach. Like a pressure cooker, the patients' anger and frustration build up and unfortunately they may lash out on staff and other patients placing them at ris ...[more]

PMID: 26734168

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Project description:BackgroundViolence towards staff working in psychiatric inpatient care is a serious problem. The aim of the present study was to explore staff perspectives of serious violent incidents involving psychiatric inpatients through the following research questions: Which factors contributed to violent incidents, according to staff? How do staff describe their actions and experiences during and after violent incidents?MethodsWe collected data via a questionnaire with open-ended questions, and captured 283 incidents reported by 181 staff members from 10 inpatient psychiatric wards in four different regions. We used the Critical Incident Technique to analyse the material. Our structural analysis started by structuring extracts from the critical incidents into descriptions, which were grouped into three chronological units of analyses: before the incident, during the incident and after the incident. Thereafter, we categorised all descriptions into subcategories, categories and main areas.ResultsStaff members often attributed aggression and violence to internal patient factors rather than situational/relational or organisational factors. The descriptions of violent acts included verbal threats, serious assault and death threats. In addition to coercive measures and removal of patients from the ward, staff often dealt with these incidents using other active measures rather than passive defence or de-escalation. The main effects of violent incidents on staff were psychological and emotional. After violent incidents, staff had to continue caring for patients, and colleagues provided support. Support from managers was reported more rarely and staff expressed some dissatisfaction with the management.ConclusionsAs a primary prevention effort, it is important to raise awareness that external factors (organisational, situational and relational) are important causes of violence and may be easier to modify than internal patient factors. A secondary prevention approach could be to improve staff competence in the use of de-escalation techniques. An important tertiary prevention measure would be for management to follow up with staff regularly after violent incidents and to increase psychological support in such situations.

Project description:BackgroundSexual violence is a global public health issue. It is a form of gender-based violence commonly experienced by women accessing mental health services. The biomedical model has been the dominant model of care in acute psychiatric units, however, there has been a global movement towards more gender-sensitive and trauma-informed models. To date, only a small amount of research has focused on evaluating these models of care and health professionals' experiences of providing this care. The aim of this study is to gain an in-depth understanding of healthcare professionals' perceptions of how Gender Sensitive Care (GSC) is enacted across acute psychiatric inpatient units for women who are survivors of sexual violence.MethodsThis study used case study methodology and the Normalisation Process Theory (NPT) conceptual framework. NPT is a practical framework that can be used to evaluate the implementation of complex models of care in health settings. It included semi-structured interviews with 40 health professionals, document and policy reviews, and observations from four psychiatric inpatient units within a large Australian public mental health organisation. Data were examined using thematic and content analysis.ResultsThemes were developed under the four NPT core constructs; 1) Understanding GSC in acute psychiatric units: "Without the corridors there's not a lot we can do", 2) Engagement and Commitment to GSC in acute psychiatric units: "There are a few of us who have that gender sensitive lens", 3) Organising, relating and involvement in GSC: "It's band aid stuff", 4) Monitoring and Evaluation of GSC in acute psychiatric units: "We are not perfect, we have to receive that feedback".DiscussionMany health professionals held a simplistic understanding of GSC and avoided the responsibility of implementing it. Additionally, the competing demands of the biomedical model and a lack of appraisal has resulted in an inconsistent enactment of GSC.ConclusionsHealth professionals in this study enacted GSC to varying levels. Our findings suggest the need to address each NPT construct comprehensively to adequately implement GSC.

Project description:ObjectiveMost guidelines for the management of aggressive behavior in acute psychiatric patients describe the use of de-escalation as the first-choice method, but the evidence for its effectiveness is inconsistent. The aim of the study was to assess the effect of verbal and non-verbal de-escalation on the incidence and severity of aggression and the use of physical restraints in acute psychiatric wards.MethodsA multi-center cluster randomized study was conducted in the acute wards of all psychiatric hospitals in Slovenia. The research was carried out in two phases, a baseline period of five consecutive months and an intervention period of the same five consecutive months in the following year. The intervention was implemented after the baseline period and included training in verbal and non-verbal de-escalation techniques for the staff teams on experimental wards.ResultsIn the baseline study period, there were no significant differences in the incidence of aggressive behavior and physical restraints between the experimental and control groups. The incidence rates of aggressive events, severe aggressive events, and physical restraints per 100 treatment days decreased significantly after the intervention. Compared to the control group, the incidence rate of aggressive events was 73% lower in the experimental group (IRR = 0.268, 95% CI [0.221; 0.342]), while the rate of severe events was 86% lower (IRR = 0.142, 95% CI [0.107; 0.189]). During the intervention period, the incidence rate of physical restraints due to aggression in the experimental group decreased to 30% of the rate in the control group (IRR = 0.304, 95% CI [0.238; 0.386]). No reduction in the incidence of restraint used for reasons unrelated to aggression was observed. After the intervention, a statistically significant decrease in the severity of aggressive incidents (p < 0.001) was observed, while the average duration of restraint episodes did not decrease.ConclusionDe-escalation training is effective in reducing the incidence and severity of aggression and the use of physical restraints in acute psychiatric units.Clinical trial registration[www.ClinicalTrials.gov], identifier [NCT05166278].

Project description:BackgroundMany psychiatric services include social inclusion as a policy with the aim to offer users the opportunity to participate in care and to form reciprocal relationships. The aim of this study was to explore opportunities and problems with regard to participation, reciprocity and social justice that different stakeholders experience when it comes to social inclusion for service users and minimizing violence in psychiatric inpatient care.MethodsQualitative interviews were performed with 12 service users, 15 staff members, and six ward managers in three different kinds of psychiatric wards in Sweden. The data were analyzed using the framework method and qualitative content analysis, which was based on the three following social inclusion values: participation, reciprocity, and social justice.ResultsThemes and subthemes were inductively constructed within the three social inclusion values. For participation, staff and ward managers reported difficulties in involving service users in their care, while service users did not feel that they participated and worried about what would happen after discharge. Staff gave more positive descriptions of their relationships with service users and the possibility for reciprocity. Service users described a lack of social justice, such as disruptive care, a lack of support from services, not having access to care, or negative experiences of coercive measures. Despite this, service users often saw the ward as being safer than outside the hospital. Staff and managers reported worries about staffing, staff competence, minimizing coercion and violence, and a lack of support from the management.ConclusionsBy applying the tentative model on empirical data we identified factors that can support or disrupt the process to create a safe ward where service users can feel socially included. Our results indicate that that staff and service users may have different views on the reciprocity of their relationships, and that users may experience a lack of social justice. The users may, due to harsh living conditions, be more concerned about the risk of violence in the community than as inpatients. Staff and ward managers need support from the management to foster a sense of community in the ward and to implement evidence-based prevention programs.

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How can we reduce violence and aggression in psychiatric inpatient units?

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How can we reduce violence and aggression in psychiatric inpatient units?

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