Exploring the Utility of a Novel Approach of Evaluating Application of a Validated Violence Risk Assessment Instrument.

Mental health nurses are often responsible for assessment/management of inpatient aggression. Validated instruments such as the Dynamic Appraisal of Situational Aggression (DASA), can aid risk assessment. However, limited attention has been paid to evaluating nurses' ability to administer risk assessment instruments. An entrustable professional activity may offer way of evaluating risk assessment clinical activities. DASA trainers' perceptions of the value and utility of an EPA were explored via collection of data through focus groups, with 17 participants from six countries. Thematic analysis was conducted to analyze the data. Three themes were interpreted: (1) DASA trainers-a way of knowing and being (2) An EPA-something you did not know you need until you see it; (3) The DASA-EPA supports the need for training and importance of integrity in assessment. Trainers engaged in innovative ways to ensure training is suitable and responsive to needs of nurses and their setting. Participants understood how an EPA could be used to evaluate DASA administration, monitor DASA use, provide feedback, and highlight the importance of training to ensure best practice.

The Model for Understanding Inpatient Aggression: A Version for Mental Health Nurses Working in Prisons.

Preventing and managing aggression remains an important and challenging task for mental health nurses. Despite the concern, there is a dearth of frameworks to assist practice and inform assessment and intervention related to aggression, for forensic mental health nurses working in prisons. This paper presents a model for understanding aggression within prison mental health units. The model elucidates various personal and situational determinants of aggression. It offers a systematic framework for mental health nurses to investigate and understand aggression, to ultimately assist nurses to provide care in an informed and effective manner, and for services to consider structural factors that contribute to the risk of aggression.

Benchmarking to reduce restrictive practices in forensic mental health services: a Delphi study.

OBJECTIVES: Forensic mental health services (FMHS) have higher rates, duration and frequency of restrictive practices (seclusion, physical restraint and mechanical restraint). Data generated by services can be used to set targets (benchmarks) with like services to reduce or eliminate restrictive practices. The aim of this study was to develop restrictive practice benchmarks for Australian and New Zealand FMHS. METHOD: A participatory action research methodology was used by conducting a Delphi study. FMHS experts provided de-identified service-specific restrictive practice data, which was used to stimulate reflection towards the development of restrictive practice benchmarks. RESULTS: Consensus decision-making was reached on benchmarks for the rate, duration and frequency of seclusion and physical restraint. Mechanical restraint was found to be a rare event, requiring event specific review in each service. CONCLUSIONS: Benchmarking with FMHS may assist in working to reduce restrictive practices and encourage the scrutiny of service practice. Establishment of a FMHS network might assist to embed the proposed benchmarks.

Risk assessment and subsequent nursing interventions in a forensic mental health inpatient setting: Associations and impact on aggressive behaviour.

AIM AND OBJECTIVES: To examine associations between risk of aggression and nursing interventions designed to prevent aggression. BACKGROUND: There is scarce empirical research exploring the nature and effectiveness of interventions designed to prevent inpatient aggression. Some strategies may be effective when patients are escalating, whereas others may be effective when aggression is imminent. Research examining level of risk for aggression and selection and effectiveness of interventions and impact on aggression is necessary. DESIGN: Archival case file. METHODS: Data from clinical files of 30 male and 30 female patients across three forensic acute units for the first 60 days of hospitalisation were collected. Risk for imminent aggression as measured by the Dynamic Appraisal of Situational Aggression, documented nursing interventions following each assessment, and acts of aggression within the 24-hours following assessment were collected. Generalised estimating equations were used to investigate whether intervention strategies were associated with reduction in aggression. RESULTS: When a Dynamic Appraisal of Situational Aggression assessment was completed, nurses intervened more frequently compared to days when no Dynamic Appraisal of Situational Aggression assessment was completed. Higher Dynamic Appraisal of Situational Aggression assessments were associated with a greater number of interventions. The percentage of interventions selected for males differed from females; males received more pro re nata medication and observation, and females received more limit setting, one-to-one nursing and reassurance. Pro re nata medication was the most commonly documented intervention (35.9%) in this study. Pro re nata medication, limit setting and reassurance were associated with an increased likelihood of aggression in some risk bands. CONCLUSIONS: Structured risk assessment prompts intervention, and higher risk ratings result in more interventions. Patient gender influences the type of interventions. Some interventions are associated with increased aggression, although this depends upon gender and risk level. RELEVANCE TO CLINICAL PRACTICE: When structured risk assessments are used, there is greater likelihood of intervention. Intervention should occur early using least restrictive interventions.

Educating emergency department nurses about trauma informed care for people presenting with mental health crisis: a pilot study.

BACKGROUND: Practicing with trauma informed care (TIC) can strengthen nurses' knowledge about the association of past trauma and the impact of trauma on the patient's current mental illness. An aim of TIC is to avoid potentially re-traumatising a patient during their episode of care. A TIC education package can provide nurses with content that describes the interplay of neurological, biological, psychological, and social effects of trauma that may reduce the likelihood of re-traumatisation. Although mental health nurses can be TIC leads in multidisciplinary environments, the translation of TIC into clinical practice by nurses working in emergency departments (EDs) is unknown. However, before ED nurses can begin to practice TIC, they must first be provided with meaningful and specific education about TIC. Therefore, the aims of this study were to; (1) evaluate the effectiveness of TIC education for ED nursing staff and (2) describe subsequent clinical practice that was trauma informed. METHODS: This project was conducted as exploratory research with a mixed methods design. Quantitative data were collected with an 18-item pre-education and post-education questionnaire. Qualitative data were collected with two one-off focus groups conducted at least three-months after the TIC education. Two EDs were involved in the study. RESULTS: A total of 34 ED nurses participated in the TIC education and 14 ED nurses participated in the focus groups. There was meaningful change (p < 0.01, r ≥ 0.35) in 9 of the 18-items after TIC education. Two themes, each with two sub-themes, were evident in the data. The themes were based on the perceived effectiveness of TIC education and the subsequent changes in clinical practice in the period after TIC education. CONCLUSION: Emergency department nurses became more informed of the interplay of trauma on an individual's mental health. However, providing care with a TIC framework in an ED setting was a considerable challenge primarily due to time constraints relative to the day-to-day ED environment and rapid turnover of patients with potentially multiple and complex presentations. Despite this, nurses understood the effect of TIC to reduce the likelihood of re-traumatisation and expressed a desire to use a TIC framework.

Testing a recovery-oriented nursing communication framework to encourage collaboration and discussion about aggression prevention: A mixed methods study.

Recovery-oriented practice is essential in healthcare, yet research exploring methods for integrating recovery-oriented principles in forensic mental health settings is limited. This study involved the co-development, with mental health care nurses and a lived experience expert, and testing of a recovery-oriented script for forensic mental health nurses to use when communicating with consumers at high-risk of imminent aggression. The aim was to examine whether nurses perceived the script as more empathic when the script included specific references to empathy, compared to an equivalent script that did not include empathic statements, and to explore nurses' perspectives on whether the script could help prevent aggression. Nurses (n = 54) working in a secure forensic mental health hospital were randomly allocated to read a script containing statements representing nine recovery-oriented principles that also included empathic statements, or an equivalent script that did not include empathic statements. After reading the script, the participants completed a questionnaire involving a recovery-oriented practice scale developed by the authors, measuring the extent to which the scripts reflected recovery-oriented principles, and open-ended questions about the script's potential to prevent aggression. Results revealed no significant difference in nurse perceptions of empathy between the two scripts. Content analysis indicated that nurses perceived the scripts could help prevent aggression.

Exploring Individual's Dynamic of Appraisal of Situational Aggression Average Score, Nursing Intervention and the Impact on Aggression.

INTRODUCTION: The Dynamic Appraisal of Situational Aggression (DASA) is used to appraise risk of imminent aggression in inpatient mental health settings. AIM: We investigated whether individual patients' mean DASA scores over multiple consecutive time periods (a rolling DASA mean) improved predictive validity, beyond the ultimate DASA rating, and whether DASA ratings were associated with nursing intervention. METHOD: Archival data were analysed using cox regression analyses. We investigated the predictive validity of rolling DASA mean models and calculated how many daily DASA ratings generated a mean score with the best model fit. Chi-Squares with Odds Ratios were used to examine the effect of various aggression prevention intervention(s) on aggression means. RESULTS: Daily DASA ratings had strong predictive validity. Incorporating the ultimate score with the rolling 10-day DASA mean slightly improved prediction. Limit setting was associated with an increased likelihood of aggression for low-risk patients whereas reassurance was associated with increased aggressiveness for those at increased risk of aggression. DISCUSSION: Daily DASA ratings have strong predictive validity. Considering a 10-day rolling DASA mean in addition to the current day DASA rating may improve prediction. IMPLICATIONS FOR PRACTICE: DASA ratings can forecast imminent aggression. Additionally, there may be value in considering ratings from the previous 10 days.

Re-Examining the Predictive Validity and Establishing Risk Levels for the Dynamic Appraisal of Situational Aggression: Youth Version.

The Dynamic Appraisal of Situational Aggression: Youth Version (DASA:YV) is a brief instrument, most often used by nurses and was specifically designed to assess risk of imminent violence in youth settings. To date, it has been recommended that DASA:YV scores are interpreted in a linear manner, with high scores indicating a greater level of risk and therefore need more assertive and immediate intervention. This study re-analyses an existing data set using contemporary robust data analytic procedures to examine the predictive validity of the DASA:YV, and to determine appropriate risk bands. Mixed effect logistic regression models were used to determine whether the DASA:YV predicted aggression when the observations are correlated. Two approaches were employed to identify and test novel DASA:YV risk bands, where (1) three risk bands as previously generated for the adult DASA were used as a starting point to consider recategorising the DASA:YV into three risk bands, and (2) using a decision tree analysis method known as Chi-square automated interaction detection to produce risk bands. There was no statistically significant difference between a four and three category of risk band. AUC values were 0.85 for the four- and three-category options. A three-category approach is recommended for the DASA:YV. The new risk bands may assist nursing staff by providing more accurate categorisation of risk state. Identification of escalation in risk state may prompt early intervention, which may also prevent reliance on the use of restrictive practices when young people are at risk of acting aggressively.

Exploring the role of the nurse unit manager in forensic mental health inpatient units: A qualitative study.

Forensic mental health (FMH) inpatient settings are complex working environments at times due to a number of factors including the presence of challenging behaviours that may include violence and aggression, restrictions related to legislation, extended length of stay and the impact of trauma. Nurse unit managers (NUMs) play an important role in managing the unit environment and clinical standards of care to achieve better outcomes for consumers and staff. However, the role of NUMs in an FMH setting is poorly understood. The overall aim of this study was to explore the role of NUMs working within an FMH setting in Victoria, Australia. To our knowledge, this is the first study that has examined the subject. Data were collected via focus groups from n = 32 participants which included NUMs, their managers, staff who work alongside the NUMs and the staff the NUMs manage. Data were analysed using thematic analysis and four themes were interpreted from the data, (i) lack of role clarity, (ii) the importance of clinical Leadership and forensic mental health knowledge, (iii) step up in responsibility and step down in pay and (iv) seeing the difference you make. The role of the NUM within a forensic mental health setting comes with a number of challenges, but also opportunities to enact change. An ongoing effort to better support those employed within the NUM role and make the role desirable for aspiring staff is critical to the sustainability of a skilled clinical workforce and quality of care in this complex setting.

A Nominal Group Technique to finalise Safewards Secure model and interventions for forensic mental health services.

WHAT IS KNOWN ON THE SUBJECT?: Safewards was developed for acute mental health units, and while could be effective in forensic mental health services, there are some gaps in the model for such services, where factors including offending behaviour and longer term care can have an influence. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The importance of acknowledging and addressing responses related to offending behaviour in forensic mental health settings, while also understanding the vulnerability of the consumer group and responsibilities to the maintenance of professional boundaries. Enhancing collaboration with consumers/families/carers/supporters is important in a forensic mental health setting, and an important element of Safewards Secure. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This study completes the development of Safewards Secure, designed to foster collaboration, address issues pertinent to forensic mental health settings to enhance implementation and acceptance of the model and reduce conflict and containment. ABSTRACT: INTRODUCTION: Safewards is a model developed for acute mental health settings designed to reduce conflict and containment; however, it requires adaptation to forensic mental health settings. AIM: To develop the Safewards Secure model, a model to assist forensic mental health services to reduce conflict and containment. METHOD: A literature review was conducted to elicit possible modifiers and adjustments to the interventions. A Nominal Group Technique was then used to engage forensic mental health experts who had experience implementing Safewards (n = 12) to seek feedback about the suggestions and reach consensus on the Safewards Secure model and interventions. Data were thematically analysed. RESULTS: Experts reached consensus on all suggestions, however, did recommend minor additions and modifications. Two themes were also interpreted: Safewards Secure is just as much for staff as it is for consumers, and the proposed additions encourage more meaningful staff to consumer collaboration. DISCUSSION: This study identified key challenges experienced by nurses working in forensic mental health settings, however, these challenges were not seen as insurmountable. The Safewards Secure model offers prompts and suggestions to encourage reflection, collaboration and a humanistic approach to care in forensic mental health settings. IMPLICATIONS FOR PRACTICE: Addressing reactions to offending behaviour and encouraging more collaboration might assist in ensuring a more person-centred approach to forensic mental health nursing care.

Modifying the clinical reasoning cycle to enhance forensic mental health nursing utility.

Forensic mental health nursing is a specialty area of practice requiring specific knowledge and skills to work collaboratively with consumers. The Clinical Reasoning Cycle has been recognised as a potential framework to support nursing practice; however, it has been identified that adaptations are required to enhance utility in a forensic mental health services. The aim of this study was to explore and finalise a version of the cycle for forensic mental health nursing practice. Focus groups and interviews were used to explore adaptations with staff from a state-wide forensic service and forensic mental health nursing academics. Data were thematically analysed. Four main themes were interpreted: (1) allegiance to the Nursing Process, (2) moving the cycle from page to practice, (3) working as a team, or not, and (4) implementation will be a marathon and not a sprint. While nursing academics were more in favour of updating the Nursing Process to ensure contemporary practice is captured, staff from the service were supportive of the adapted cycle but emphasised the need to ensure collaboration with the consumer and their supporters. The adapted cycle was seen to articulate the contribution of forensic mental health nursing care, and support for a nursing-specific cycle was embraced by other disciplines, despite some hesitation from nurses. Prior to implementation there is a need to ensure the merits of the cycle are clearly articulated, along with a range of resources and specific contextual information to ensure the cycle can be successfully applied to enhance nursing practice and consumer care.

Developing entrustable professional activities to enhance application of an aggression prevention protocol.

AIM: The research aim of this study was to seek feedback from prevention of aggression training experts about the suitability of Entrustable Professional Activities (EPAs) as an assessment tool for an Aggression Prevention Protocol. The protocol was designed to structure intervention to prevent aggression and reduce the use of restrictive practices following risk assessment using a validated instrument (the Dynamic Appraisal of Situational Aggression). BACKGROUND: Preventing aggression and limiting the use of restrictive practices are key priorities for inpatient mental health services. Assessing clinical activities using a competence framework has limitations, particularly when determining complex interventions. EPAs could provide a suitable method for assessing complex clinical activities like de-escalation and limit setting, which comprise some of the interventions in the Aggression Prevention Protocol. EPAs are new to forensic mental health nursing; therefore, feedback was sought regarding the utility of EPAs to assess aggression prevention interventions. METHODS: Data were collected via focus groups including 11 aggression prevention experts from Australia and New Zealand. A thematic analysis, comparative analysis and a Strength, Weakness, Opportunity and Threats analysis was conducted. RESULTS: Three themes were interpreted from the data: 1) Frameworks such as the APP are needed to work towards elimination of restrictive practices; 2) APP-EPAs afford an opportunity to set the standard for practice; and 3) 'who watches the watchers', were identified by the experts as well as areas to enhance EPAs prior to introduction into practice. CONCLUSIONS: EPAs address a practice-gap and offer a framework to assist movement towards elimination of restrictive practices, while prompting best-practice, self-reflection and practice improvement guidance.

Exploring adaptations to the clinical reasoning cycle for forensic mental health nursing: A qualitative enquiry.

Forensic mental health nurses (FMHN) provide care to address the needs of people who have mental illnesses across a range of diverse settings. The Clinical Reasoning Cycle (CRC) has been identified as a potential framework to assist FMHNs; however, adaptations were required to reflect the unique nature of the clinical setting. This study aimed to explore adaptations made to determine suitability prior to implementation in practice. Nominal Group Technique was used to explore suggested adaptations determined from a previous study and reach a consensus on the changes. Fourteen senior nurses from a state-wide Forensic mental Health (FMH) service participated. A consensus was reached for two proposed changes. Data were analysed using thematic analysis. Three main themes were interpreted from the data; FMH adaptations are warranted, the focus of the CRC, and who owns the cycle? Nurses in this study considered the need to include offence and risk issues due to the impact these factors have on the therapeutic relationship and cognitive bias; however, they also identified the need to focus on recovery-oriented care while engaging in clinical reasoning. Nurses in this study also expressed some reluctance for nursing to 'own' the model, due to concern that ownership may cause division among the team or result in inconsistency in care. However, some participant's suggested the CRC with adaptations assisted FMH nurses to articulate their specialist skills and knowledge to others and highlight the nursing contribution to care. Further work is needed to finalize adaptations with a focus on engaging the consumer carer workforce and interdisciplinary team.

Using the Dynamic Appraisal of Situational Aggression (DASA) to assess the impact of unit atmosphere on violence risk assessment.

WHAT IS KNOWN ON THE SUBJECT: Research suggests that the Dynamic Appraisal of Situational Aggression (DASA) is a useful risk assessment instrument to identify individuals who might be at risk of aggression in mental health inpatient units. Although, risk assessment research has typically focused on an individual's risk of aggression, recent research has begun exploring whether the DASA could be used to assess the likelihood that a group of patients would be aggressive. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE: While the DASA was useful for assessing whether an individual was likely to be aggressive, the group average score was not a useful indicator for the likelihood of aggression once the individual DASA score was taken into consideration. Unexpectedly, patients who were assessed as high risk on the DASA were more likely to be aggressive on settled units compared to unsettled units, which included other individuals whose risk was elevated. WHAT ARE THE IMPLICATIONS FOR PRACTICE: There is not enough evidence to suggest that the group DASA average improves the identification of aggression above the individual DASA score. ABSTRACT: INTRODUCTION: The Dynamic Appraisal of Situational Aggression (DASA) is an inpatient aggression risk assessment instrument. Recently, research explored whether the unit atmosphere, as indicated by a unit's average DASA score, was related to inpatient aggression risk, but failed to control for individual risk. AIM: Investigate whether the DASA unit average score or an interaction between the unit average and an individual patient's DASA score was related to the likelihood that an individual would act aggressively. METHOD: Cox regression with repeated assessments and recurrent events was used to analyse 11,243 DASA risk assessments of 113 inpatients collected via retrospective file review. RESULTS: The unit DASA average score was not related to aggression towards staff. There was a negative interaction between the individual and the unit DASA average scores when identifying patient-to-patient aggression; high-risk patients engaged in less aggression when the unit average was heightened relative to units with lower DASA average scores. DISCUSSION: It is possible that there were more nursing interventions and/or patients engaged in greater self-regulation on unsettled units, thus reducing aggression. IMPLICATIONS FOR PRACTICE: Currently, there is insufficient evidence to suggest that the unit average score should be used to supplement individual DASA scores to identify aggression risk.

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.

Establishing best practice in violence risk assessment and violence prevention education for nurses working in mental health units.

OBJECTIVES: To explore and evaluate extant and potential methods used in risk assessment and aggression prevention training. This study was also designed to consider the most appropriate method for educating nurses in use of a novel risk assessment instrument linked to a structured nursing intervention protocol (the electronic application of the Dynamic Appraisal of Situational Aggression and Aggression Prevention Protocol). BACKGROUND: Organisational and personal concerns have led to the development of training programs designed to prevent and manage aggression in mental health units. DESIGN: This descriptive qualitative study explored experts' opinions about effective training approaches. METHODS: Data were collected via focus groups (a total of four discrete groups), with each of the four focus groups repeated after four weeks. A semi-structured guide was used to guide the focus group discussions. RESULTS: Seventeen experts with experience coordinating and facilitating training in prevention and management of aggression in mental health units in New Zealand and Australia participated in this study. Three themes emerged from the data 1) existing training can be "like pulling teeth without anaesthetic" 2) the need to "breathe life" into the training and 3) a vision of the "gold standard" for practice and training. CONCLUSIONS: Training is optimal when it is place-based, responsive to local needs and inclusive of relevant clinical, cultural, consumer/carer and contextual factors. Training may benefit from a focus on the application of the knowledge, skills and attitudes learnt and there is a need for ongoing reinforcement of training in the clinical setting, beyond initial introduction and provision of information and orientation to relevant skills.

Using the Nominal Group Technique to determine a nursing framework for a forensic mental health service: A discussion paper.

The Nominal Group Technique is a method used to explore issues, generate ideas, and reach consensus on a topic. The Nominal Group Technique includes individual and group work and is designed to ensure participants have the same opportunity to engage and provide their opinions. While the technique has been used for around six decades to assist groups, in industry, and government organizations to examine issues and make decisions, this technique has received limited attention in nursing research, particularly in mental health. This discussion paper describes the use of a modified Nominal Group Technique for a study designed to determine a nursing decision-making framework for a state-wide forensic mental health service. Modifications were made to the traditional technique, to enable participants to make an informed and collective decision about a suitable framework for the novice to expert nurses, across secure inpatient, prison, and community forensic mental health settings. The Nominal Group Technique generated rich data and offered a structured approach to the process. We argue that the Nominal Group Technique offers an exciting and interactive method for nursing research and can increase opportunity for minority group members to participate. This technique also offers a time efficient way to engage busy clinical nurses to participate in research, with the advantage of members knowing the decision on the day of the group. Consideration, however, needs to be given to the duration and effect on participant concentration, and if not actively managed by facilitators, the possible emergence of group dynamics affecting individuals' decisions.

Exploration of the utility of the Nursing Process and the Clinical Reasoning Cycle as a framework for forensic mental health nurses: A qualitative study.

Forensic mental health nursing (FMHN) is a specialized field, designed to meet the needs of people who have a serious mental illness across the criminal justice system, inpatient services and community. Frameworks can assist assessment, planning, intervention, documentation and evaluation of nursing care. However, there is no prior research investigating frameworks in FMHN. This study aimed to explore the Nursing Process (NP) and the Clinical Reasoning Cycle (CRC), with nurses, to determine a suitable framework for use service-wide. A Nominal Group Technique was used to facilitate exploration of the two frameworks, where open-ended verbal and written responses collected from a Nominal Group were thematically analysed, and the participants voted on their preferred framework. Seventeen nurses from a state-wide forensic mental health (FMH) service participated. The four main themes were as follows: challenges to current practice, limitations of the NP, perceived benefits of the CRC and addressing implementation. Consensus was reached with the nurses selecting the CRC as the framework of choice. This is the first study to explore frameworks to guide practice in FMHN. Nurses in this study considered the CRC to be a suitable framework for novice through to expert, offering a contemporary framework to guide nursing care in complex FMH settings. Some adjustments to the existing cycle were suggested to emphasize recovery-oriented practice, and inclusion of family and carers. Any changes to the cycle warrant exploration with the interdisciplinary team and consumer carer workforce.

A Clinical Decision Support System to Prevent Aggression and Reduce Restrictive Practices in a Forensic Mental Health Service.

OBJECTIVE: Preventing aggression and reducing restrictive practices in mental health units rely on routine, accurate risk assessment accompanied by appropriate and timely intervention. The authors studied the use of an electronic clinical decision support system that combines two elements, the Dynamic Appraisal of Situational Aggression instrument and an aggression prevention protocol (eDASA+APP), in acute forensic mental health units for men. METHODS: The authors conducted a cluster-randomized controlled trial incorporating a crossover design with baseline, intervention, and washout periods in a statewide, secure forensic mental health service. The study included 36 mental health nurses (13 men and 23 women, ages 20-65 years) with direct patient care responsibility and 77 male patients (ages 21-77 years) admitted to one of two acute mental health units during the baseline and intervention periods. RESULTS: eDASA+APP implementation was associated with a significant reduction in the odds of an aggressive incident (OR=0.56, 95% confidence interval [95% CI]=0.45-0.70, p<0.001) and a significant decrease in the odds of administration of as-needed medication (OR=0.64, 95% CI=0.50-0.83, p<0.001). Physical aggression was too infrequent for statistical significance of any effects of eDASA+APP to be determined; however, incidents of physical aggression tended to be fewer during the eDASA+APP phase. CONCLUSIONS: These results support the use of the eDASA+APP to help reduce incidents of aggression and restrictive practices in mental health units.

Evaluating the impact of an electronic application of the Dynamic Appraisal of Situational Aggression with an embedded Aggression Prevention Protocol on aggression and restrictive interventions on a forensic mental health unit.

Risk assessment is a pre-requisite for violence prevention in mental health settings. Extant research concerning risk assessment and nursing intervention is limited and has focused on the predictive validity of various risk assessment approaches and instruments, with few attempts to elucidate and test interventions that might prevent aggression, and reduce reliance on coercive interventions. The integration of risk assessment and violence prevention strategies has been neglected. The aim of this feasibility study was to test a novel Aggression Prevention Protocol designed to prioritize the instigation of less restrictive interventions on an acute forensic mental health unit for female patients. A prospective quasi-experimental study was designed to test an Aggression Prevention Protocol, linked to an electronic application of the Dynamic Appraisal of Situational Aggression (DASA). Following introduction of the DASA and Aggression Prevention Protocol, there were reductions in verbal aggression, administration of Pro Re Nata medication, the rate of seclusion, and physical and mechanical restraint. There was also an increase in documented nursing interventions. Overall, these results support further testing of the electronic application of the DASA and the Aggression Prevention Protocol.