The physical and mental health of acute psychiatric ward staff, and its relationship to experience of physical violence.

To evaluate and describe the physical and mental health of staff on acute psychiatric wards and examine whether violence exposure is linked with health status. We undertook a cross-sectional survey with 564 nursing staff and healthcare assistants from 31 psychiatric wards in nine NHS Trusts using the SF-36, a reliable and valid measure of health status and compared summary scores with national normative data. Additional violence exposure data were collated simultaneously and also compared with health status. The physical health of staff was worse, and their mental health was better than the general population. Physical health data were skewed and showed a small number of staff in relatively poor health while the majority were above average. Better physical health was associated with less time in the current post, a higher pay grade, and less exposure to mild physical violence in the past year. Better mental health was associated with being older and from an ethnic minority background. Violence exposure influenced physical health but not mental health when possible confounders were considered. Mental health was strongly influenced by ethnicity, and further research might highlight the impact on own-group ethnic density on the quality of care. The impact of staff whom are physically unwell or impaired in the workplace needs to be considered as the quality of care may be compromised despite this being an example of inclusiveness, equal opportunities employment, and positive staff motivation.

Acceptability and use of coercive methods across differing service configurations with and without seclusion and/or psychiatric intensive care units.

AIMS: The aim of this study was to compare across different service configurations the acceptability of containment methods to acute ward staff and the speed of initiation of manual restraint. BACKGROUND: One of the primary remits of acute inpatient psychiatric care is the reduction in risks. Where risks are higher than normal, patients can be transferred to a psychiatric intensive care unit or placed in seclusion. The abolition or reduction in these two containment methods in some hospitals may trigger compensatory increases in other forms of containment which have potential risks. How staff members manage risk without access to these facilities has not been systematically studied. DESIGN: The study applied a cross-sectional design. METHODS: Data were collected from 207 staff at eight hospital sites in England between 2013 - 2014. Participants completed two measures; the first assessing the acceptability of different forms of containment for disturbed behaviour and the second assessing decision-making in relation to the need for manual restraint of an aggressive patient. RESULTS: In service configurations with access to seclusion, staff rated seclusion as more acceptable and reported greater use of it. Psychiatric intensive care unit acceptability and use were not associated with its provision. Where there was no access to seclusion, staff were slower to initiate restraint. There was no relationship between acceptability of manual restraint and its initiation. CONCLUSION: Tolerance of higher risk before initiating restraint was evident in wards without seclusion units. Ease of access to psychiatric intensive care units makes little difference to restraint thresholds or judgements of containment acceptability.

Physical injury and workplace assault in UK mental health trusts: An analysis of formal reports.

Workplace violence is a significant problem for health service personnel, with National Health Service (NHS) workers subject to 68 683 physical assaults between 2013 and 2014. Almost 70% of assaults occur in the mental health sector, and although serious, non-fatal injury is rare, the individual and economic impact can be substantial. In the present study, we analysed mandatory incident reports from a national database to examine whether there were identifiable precursors to incidents leading to staff injury, and whether staff characteristics were associated with injury. In line with previous descriptions, we found injury occurred either as a direct result of patient assault or during physical interventions employed by staff to contain aggression. Importantly, we found little evidence from staff reports that patients' symptoms were driving aggression, and we found less evidence of patient perspectives among reports. We make several recommendations regarding the reporting of these events that could inform policy and interventions aimed at minimizing the likelihood of injury.

Predictors of effective de-escalation in acute inpatient psychiatric settings.

AIMS AND OBJECTIVES: To explore the factors that influence the use of de-escalation and its success in halting conflict in acute psychiatric inpatient setting. BACKGROUND: De-escalation is the use of verbal and nonverbal communication to reduce or eliminate aggression and violence during the escalation phase of a patient's behaviour. Although de-escalation is a first-line intervention in aggression management in acute psychiatric settings, little is known about the use or effectiveness of this technique. DESIGN: A retrospective case note analysis. METHODS: For each patient (n = 522), their involvement in conflict (e.g. aggression) or containment (e.g. coerced medication) during the first two weeks of their admission was recorded. The frequency and order of the conflict and containment events were identified during each shift. The sequences of events occurring in shifts involving de-escalation were analysed. Sequences where de-escalation ended the pattern of conflict or containment were categorised as 'successful', and all others were categorised as 'unsuccessful'. RESULTS: Over half of patients (53%) experienced de-escalation during the first two weeks of admission, with the majority of these (37%) experiencing multiple episodes. De-escalation was successful in approximately 60% of cases. Successful de-escalations were preceded by fewer, and less aggressive, conflict events, compared with unsuccessful de-escalations, which were most frequently followed by administration of pro re nata medication. Patients with a history of violence were more likely to experience de-escalation, and it was more likely to be unsuccessful. CONCLUSIONS: De-escalation is frequently effective in halting a sequence of conflict in acute inpatient settings, but patients with a history of violence may be specifically challenging. RELEVANCE TO CLINICAL PRACTICE: These findings provide support for de-escalation in practice but suggest that nurses may lack confidence in using the technique when the risk of violence is greater. Providing evidence-based staff training may improve staff confidence in the use of this potentially powerful technique.

Aggression on inpatient units: Clinical characteristics and consequences.

Aggression and violence are widespread in UK Mental Health Trusts, and are accompanied by negative psychological and physiological consequences for both staff and other patients. Patients who are younger, male, and have a history of substance use and psychosis diagnoses are more likely to display aggression; however, patient factors are not solely responsible for violence, and there are complex circumstances that lead to aggression. Indeed, patient-staff interactions lead to a sizeable portion of aggression and violence on inpatient units, thus they cannot be viewed without considering other forms of conflict and containment that occur before, during, and after the aggressive incident. For this reason, we examined sequences of aggressive incidents in conjunction with other conflict and containment methods used to explore whether there were particular profiles to aggressive incidents. In the present study, 522 adult psychiatric inpatients from 84 acute wards were recruited, and there were 1422 incidents of aggression (verbal, physical against objects, and physical). Cluster analysis revealed that aggressive incident sequences could be classified into four separate groups: solo aggression, aggression-rule breaking, aggression-medication, and aggression-containment. Contrary to our expectations, we did not find physical aggression dominant in the aggression-containment cluster, and while verbal aggression occurred primarily in solo aggression, physical aggression also occurred here. This indicates that the management of aggression is variable, and although some patient factors are linked with different clusters, these do not entirely explain the variation.

Nursing interventions for substance use during psychiatric hospital admissions: Clinical context and predictors.

Empirical information about how nurses manage substance use on psychiatric wards is lacking. The aims of the study were to identify the frequency and clinical features of incidents among a sample of inpatients over a 12-month period and how nursing staff intervened. Electronic, anonymized inpatient records were searched for incidents of substance use on 17 acute psychiatric wards in four hospitals in London. Searches were conducted for all patients admitted during 2012 and details of incidents and patient characteristics were extracted for analysis. Substance use was reported for 291 patients, with 25 incidents per 100 patients admitted to hospital. Only half of the incidents were followed by a response that specifically addressed the patients' substance use behaviour. These interactions usually concerned the circumstances and reasons for use, but rarely involved specific support for patients' substance use problems. The likelihood of staff taking any form of action was increased if the patient had been formally admitted, and was reduced if the patient was subject to containment during the shift or had a history of self-harm. The results demonstrate that nurses require specific training and guidance on supporting substance using patients.

Describing the precursors to and management of medication nonadherence on acute psychiatric wards.

OBJECTIVE: This study aims to (a) describe what conflict (aggression, absconding etc.) and containment (de-escalation, restraining etc.) events occur before and after events of medication nonadherence on acute psychiatric wards and (b) identify which patient characteristics are associated with medication nonadherence. METHOD: Conflict and containment events for each shift over the first 2 weeks of admission were coded retrospectively from nursing records for a sample of 522 adult psychiatric inpatients. The frequency and order of the conflict and containment events were identified. Univariate logistic regression models were conducted to examine which patient characteristics were linked with medication noncompliance. RESULTS: Medication refusals were commonly preceded by aggression whereas demands for pro re nata (PRN) (psychotropic) were commonly preceded by the same patient having been given PRN medication. Refusals and demands for medication were commonly followed by de-escalation and given PRN (psychotropic) medication. Only refusal of PRN medication was commonly followed by forced (intramuscular) medication. Ethnicity, previous self-harm and physical health problems were also linked to nonadherence. CONCLUSIONS: Greater attention to the conflict and containment events that precede and follow medication nonadherence may reduce the likelihood of medication nonadherence.

Reducing conflict and containment rates on acute psychiatric wards: The Safewards cluster randomised controlled trial.

BACKGROUND: Acute psychiatric wards manage patients whose actions may threaten safety (conflict). Staff act to avert or minimise harm (containment). The Safewards model enabled the identification of ten interventions to reduce the frequency of both. OBJECTIVE: To test the efficacy of these interventions. DESIGN: A pragmatic cluster randomised controlled trial with psychiatric hospitals and wards as the units of randomisation. The main outcomes were rates of conflict and containment. PARTICIPANTS: Staff and patients in 31 randomly chosen wards at 15 randomly chosen hospitals. RESULTS: For shifts with conflict or containment incidents, the experimental condition reduced the rate of conflict events by 15% (95% CI 5.7-23.7%) [corrected] relative to the control intervention. The rate of containment events for the experimental intervention was reduced by 23.2% (95% CI 9.9-35.5%). [corrected] CONCLUSIONS: Simple interventions aiming to improve staff relationships with patients can reduce the frequency of conflict and containment. TRIAL REGISTRATION: IRSCTN38001825.

Thematic analysis of psychiatric patients' perceptions of nursing staff.

Therapeutic and informal interactions with nurses are integral to the quality of care that psychiatric patients receive. How well these interactions are performed, and their impact on the experience and outcomes of inpatient care, have not been subject to systematic evaluation. The aim of the present study was to examine patients' perceptions of the personal and professional qualities of nursing staff and how these contribute to the ward environment. Patients (n = 119) from 16 acute psychiatric wards were interviewed using a schedule developed by a service-user researcher. Transcriptions of interviews were coded and organized into six themes: staff duties, staff disposition, control, communication and engagement, therapeutic ward environment, and consistency. Patients recognized that nurses have a difficult and stressful job, but frequently expressed feelings of anger, frustration, and hopelessness about their experience of the wards. Patients frequently felt that nursing staff did not understand issues from their perspective or attempt to empathize with them. The findings indicate poorly-communicated and inconsistent care. Initiatives to improve patients' experiences of acute psychiatric wards are urgently needed.

Patients subject to high levels of coercion: staff's understanding.

Measures to keep staff and patients safe (containment) frequently involve coercion. A small proportion of patients is subject to a large proportion of containment use. To reduce the use of containment, we need a better understanding of the circumstances in which it is used and the understandings of patients and staff. Two sweeps were made of all the wards, spread over four hospital sites, in one large London mental health organization to identify patients who had been subject to high levels of containment in the previous two weeks. Data were then extracted from their case notes about their past history, current problem behaviours, and how they were understood by the patients involved and the staff. Nurses and consultant psychiatrists were interviewed to supplement the information from the case records. Twenty-six heterogeneous patients were identified, with many ages, genders, diagnoses, and psychiatric specialities represented. The main problem behaviours giving rise to containment use were violence and self-harm. The roots of the problem behaviours were to be found in severe psychiatric symptoms, cognitive difficulties, personality traits, and the implementation of the internal structure of the ward by staff. Staff's range and depth of understandings was limited and did not include functional analysis, defence mechanisms, specific cognitive assessment, and other potential frameworks. There is a need for more in-depth assessment and understanding of patients' problems, which may lead to additional ways to reduce containment use.

Results of a pilot randomised controlled trial to measure the clinical and cost effectiveness of peer support in increasing hope and quality of life in mental health patients discharged from hospital in the UK.

BACKGROUND: Mental health patients can feel anxious about losing the support of staff and patients when discharged from hospital and often discontinue treatment, experience relapse and readmission to hospital, and sometimes attempt suicide. The benefits of peer support in mental health services have been identified in a number of studies with some suggesting clinical and economic gains in patients being discharged. METHODS: This pilot randomised controlled trial with economic evaluation aimed to explore whether peer support in addition to usual aftercare for patients during the transition from hospital to home would increase hope, reduce loneliness, improve quality of life and show cost effectiveness compared with patients receiving usual aftercare only, with follow-up at one and three-months post-discharge. RESULTS: A total of 46 service users were recruited to the study; 23 receiving peer support and 23 in the care-as-usual arm. While this pilot trial found no statistically significant benefits for peer support on the primary or secondary outcome measures, there is an indication that hope may be further increased in those in receipt of peer support. The total cost per case for the peer support arm of the study was £2154 compared to £1922 for the control arm. The mean difference between costs was minimal and not statistically significant. However, further analyses demonstrated that peer support has a reasonably high probability of being more cost effective for a modest positive change in the measure of hopelessness. Challenges faced in recruitment and follow-up are explored alongside limitations in the delivery of peer support. CONCLUSIONS: The findings suggest there is merit in conducting further research on peer support in the transition from hospital to home consideration should be applied to the nature of the patient population to whom support is offered; the length and frequency of support provided; and the contact between peer supporters and mental health staff. There is no conclusive evidence to support the cost effectiveness of providing peer support, but neither was it proven a costly intervention to deliver. The findings support an argument for a larger scale trial of peer support as an adjunct to existing services. TRIAL REGISTRATION: Current Controlled Trials ISRCTN74852771.

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

Although individual conflict and containment events among acute psychiatric inpatients have been studied in some detail, the relationship of these events to each other has not. In particular, little is known about the temporal order of events for individual patients. This study aimed to identify the most common pathways from event to event. A sample of 522 patients was recruited from 84 acute psychiatric wards in 31 hospital locations in London and the surrounding areas during 2009-2010. Data on the order of conflict and containment events were collected for the first two weeks of admission from patients' case notes. Event-to-event transitions were tabulated and depicted diagrammatically. Event types were tested for their most common temporal placing in sequences of events. Most conflict and containment occurs within and between events of the minimal triangle (verbal aggression, de-escalation, and PRN medication), and the majority of these event sequences conclude in no further events; a minority transition to other, more severe, events. Verbal abuse and medication refusal were more likely to start sequences of disturbed behaviour. Training in the prevention and management of violence needs to acknowledge that a gradual escalation of patient behaviour does not always occur. Verbal aggression is a critical initiator of conflict events, and requires more detailed and sustained research on optimal management and prevention strategies. Similar research is required into medication refusal by inpatients.

Measurement and monitoring of health care worker aggression exposure.

Aggression exposure is highly prevalent in healthcare workers, and is a complex problem that negatively impacts patient and worker safety and health. Typically only events of high severity (e.g., use of physical restraint or incident reports) are monitored in healthcare settings. Unfortunately, these events are likely a small fraction of all aggressive events that range from verbal to physical. Improved measurement and monitoring of healthcare worker aggression exposure may lead to improved patient and worker safety and health. This article provides an overview of aggression exposure in healthcare and reviews the measurement of aggression, including challenges and common measures. Discussion of a pilot study presents insights gained from using a novel measure of aggression, handheld counters. The conclusion offers implications for research and clinical practice.

Correlation between levels of conflict and containment on acute psychiatric wards: the city-128 study.

OBJECTIVE Attainment of safe, calm inpatient psychiatric wards that are conducive to positive therapeutic care is crucial. On such wards, rates of coerced medication, seclusion, manual restraint and other types of containment are comparatively low, and, usually, rates of conflict-for example, aggression, substance use, and absconding-are also low. Sometimes, however, wards maintain low rates of containment even when conflict rates are high. This study investigated wards with the counterintuitive combination of low containment and high conflict or high containment and low conflict. METHODS The authors conducted a secondary analysis of cross-sectional data collected from 136 acute psychiatric wards across England in 2004-2005. The wards were categorized into four groups on the basis of median splits of containment and conflict rates: high conflict and high containment, high conflict and low containment, low conflict and low containment, and low conflict and high containment. Features significantly associated with these ward types were identified. RESULTS Among the variables significantly associated with the various typologies, some-for example, environmental quality-were changeable, and others-such as social deprivation of the area served-were fixed. High-conflict, low-containment wards had higher rates of male staff and lower-quality environments than other wards. Low-conflict, high-containment wards had higher numbers of beds. High-conflict, high-containment wards utilized more temporary staff as well as more unqualified staff. No overall differences were associated with low-conflict, low-containment wards. CONCLUSIONS Wards can make positive changes to achieve a low-containment, nonpunitive culture, even when rates of patient conflict are high.

Behavioural antecedents to pro re nata psychotropic medication administration on acute psychiatric wards.

This study examined the antecedents to administration of pro re nata (PRN) psychotropic medication on acute psychiatric wards, with a particular focus on its use in response to patient aggression and other conflict behaviours. A sample of 522 adult in-patients was recruited from 84 acute psychiatric wards in England. Data were collected from nursing and medical records for the first 2 weeks of admission. Two-thirds of patients received PRN medication during this period, but only 30% of administrations were preceded by patient conflict (usually aggression). Instead, it was typically administered to prevent escalation of patient behaviour and to help patients sleep. Overall, no conflict behaviours or further staff intervention occurred after 61% of PRN administrations. However, a successful outcome was less likely when medication was administered in response to patient aggression. The study concludes that improved monitoring, review procedures, training for nursing staff, and guidelines for the administration of PRN medications are needed.

Conflict and containment events in inpatient psychiatric units.

AIMS AND OBJECTIVES: To describe the types and frequency of conflict behaviours exhibited by patients during the first 2 weeks of admission to acute psychiatric units, the methods staff use to manage them and bring to the surface underlying common patterns. BACKGROUND: Many studies have investigated the prevalence and impact of psychiatric inpatient aggression. Much of the research to date has studied conflict and containment behaviours separately; however, some studies have reported relationships between certain behaviours suggesting that there are complex causal links between conflict and containment behaviours. DESIGN: A cross-sectional survey of conflict and containment events. METHODS: Nursing notes were accessed for 522 patients during the first 2 weeks of admission, in 84 wards in 31 hospitals in the South East of England. Conflict and containment events occurring during this period were recorded retrospectively. RESULTS: Factor analysis revealed six patterns of conflict behaviour, which were related to containment methods and patient demographic factors. These factors confirm some previously reported patterns of conflict. CONCLUSIONS: This study brings to light underlying common patterns of disruptive behaviour by psychiatric inpatients. The reasons for these remain obscure, but may relate to (1) national variations in policy and practice shaping static structural differences of interest between patients and staff and (2) normal developmental age and gender-specific behaviours. RELEVANCE TO CLINICAL PRACTICE: Conflict behaviour patterns may be differently motivated and therefore require different management strategies by staff. There is a need for awareness by clinical staff to the fact that different types of conflict behaviours may be co-occurring or indicative of each other. Clinical staff should consider that implementation of and changes to hospital policies have the potential to change the nature and frequencies of certain conflict behaviours by patients.

Self harm in adult inpatient psychiatric care: a national study of incident reports in the UK.

BACKGROUND: We know little about the nature of self harming behaviour within inpatient psychiatric services. The few studies in this area have mainly investigated the correlates self harm, or have been restricted to forensic services, within single hospitals. OBJECTIVES: To describe the demographic characteristics of those who self harm, and the characteristics of self harming behaviour within adult psychiatric wards across the UK. METHODS: Analysis of 500 reports of self harm within inpatient services across England and Wales, randomly selected from a total of 14,271 reports collected by the National Patient Safety Agency. RESULTS: Most episodes of self harm were by women, and did not put the service user's life at risk. The most common form of self harm involved breaking the skin. Women were more likely to use methods of restricting their breathing, whilst men were more likely to use outwardly aggressive methods. Self harm was often a private act, which took place in bedrooms, bathrooms and toilets, and during the evening hours. Taking into account the numbers of beds within each service nationally, there were more episodes of self harm within forensic services. The most common interventions for self harm were verbal de-escalation, and manual restraint. The most common antecedents to self harm were a distressing psychological state, conflict behaviours (behaviours which threatened staff, or service user safety), and conflict with staff. CONCLUSIONS: Self harm within inpatient care constitutes a wide range of behaviours, and it may be useful for clinicians to discuss the particular meaning of the methods of self harm used with service users. In general, self harm is a private act, suggesting that most acts of self harm are not intended to have an impact on others. More research into the social nature of self harm, and the meaning of different self harming behaviours (particularly outwardly aggressive methods of self harm such as headbanging), would help to increase our understanding of these acts, and develop more appropriate ways of supporting service users. Future research should also investigate how staff behaviour may contribute to self harm. The development of a reporting system which requires a detailed account of incidents would aid future research in these areas.

Patient characteristics and behaviours associated with self-harm and attempted suicide in acute psychiatric wards.

AIMS AND OBJECTIVES: The study examined events before and after incidents of self-harm and attempted suicide and the characteristics of patients who engage in these behaviours. BACKGROUND: Psychiatric inpatient populations have an elevated risk of self-harm and suicide, but relatively little is known about the circumstances of these events during an admission. DESIGN: Retrospective case note analysis. METHOD: Data were collected on conflict (aggression, rule breaking, etc.) and containment (coerced medication, restraint, etc.) during the first two weeks of admission for a sample of 522 acute psychiatric inpatients. RESULTS: One in 10 patients self-harmed, and 4% attempted suicide. Aggression, attempting to leave the ward without permission and medication refusal were frequent precursors to incidents. Pro re nata medication and de-escalation were the most frequent interventions to follow an incident. Self-harm and attempted suicides during the current admission were significantly associated with younger age and a history of self-harm. CONCLUSIONS: A minority of the sample were involved in these behaviours, but incidents occurred soon after admission and sometimes repeatedly during the course of a day. Assessment of risk should be completed as early as possible. RELEVANCE TO CLINICAL PRACTICE: At-risk patients should be monitored for signs of withdrawal from ward activity, wanting to leave the ward without permission or non-compliance with medication to enable early intervention.