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.

The feasibility of delivering the ADVANCE digital intervention to reduce intimate partner abuse by men receiving substance use treatment: protocol for a non-randomised multi-centre feasibility study and embedded process evaluation.

BACKGROUND: Compared to men in the general population, men in substance use treatment are more likely to perpetrate intimate partner abuse (IPA). The ADVANCE group intervention for men in substance use treatment is tailored to address substance use and IPA in an integrated way. In a feasibility trial pre-COVID, men who received the ADVANCE intervention via face-to-face group delivery showed reductions in IPA perpetration. Due to COVID-19, ADVANCE was adapted for remote digital delivery. METHODS/DESIGN: This mixed-methods non-randomised feasibility study, with a nested process evaluation, will explore the feasibility and acceptability of delivering the ADVANCE digital intervention to men in substance use treatment who have perpetrated IPA towards a female partner in the past year. Sixty men will be recruited from seven substance use treatment services in Great Britain. The ADVANCE digital intervention comprises a preparatory one-to-one session with a facilitator to set goals, develop a personal safety plan, and increase motivation and a preparatory online group to prepare men for taking part in the intervention. The core intervention comprises six fortnightly online group sessions and 12 weekly self-directed website sessions to recap and practise skills learned in the online group sessions. Each website session is followed by a one-to-one video/phone coaching session with a facilitator. Men will also receive their usual substance use treatment. Men's female (ex) partners will be invited to provide outcome data and offered support from integrated safety services (ISS). Outcome measures for men and women will be sought post intervention (approximately 4 months post male baseline interview). Feasibility parameters to be estimated include eligibility, suitability, consent, recruitment, attendance, retention and follow-up rates. In-depth interviews or focus groups will explore the intervention's acceptability to participants, facilitators and ISS workers. A secondary focus of the study will estimate pre-post-differences in outcome measures covering substance use, IPA, mental health, self-management, health and social care service use, criminal justice contacts and quality of life. DISCUSSION: Findings will inform the design of a multicentre randomised controlled trial evaluating the efficacy and cost-effectiveness of the ADVANCE digital intervention for reducing IPA. TRIAL REGISTRATION: The feasibility study was prospectively registered: ISRCTN66619273 .