Implementation of guidelines on prevention of coercion and violence (PreVCo) in psychiatry: a multicentre randomised controlled trial.

Background: Interventions to prevent the use of coercion in psychiatric hospitals have been summarized in the 2018 German Association for Psychiatry, Psychotherapy, and Psychosomatic's comprehensive guidelines. Twelve recommendations for implementation of these guideline on psychiatric wards have been deducted and their feasibility has been tested in a pilot study, using external implementation consultants as facilitators. The objective of the PreVCo study was to test their effect in a randomised clinical trial. Methods: Fifty-four psychiatric wards in Germany treating voluntary and involuntary patients were randomly allocated to either an intervention or to a waiting list condition. The intervention consisted of the implementation of three out of 12 suggested recommendations as selected by the ward teams, supported by external study workers. As the primary outcome measure, the number of coercive measures used per bed and month in the final 3 months of the intervention period was determined. Secondary outcomes were the cumulative duration of coercive measures used per bed and months and assaults per bed and month. Achieved guideline adherence was measured by a fidelity scale developed for this purpose during a pilot study for the PreVCo Rating Tool. After a 3-month baseline collection period under routine conditions, randomisation was done after matching wards pairwise according to frequency of coercive measures used and scores on the PreVCo Rating Tool at baseline. The duration of the intervention period was 12 months; control wards received only an initial workshop presentation of the study and completed their PreVCo ratings. We used the Wilcoxon signed rank test and the paired t-test and conducted sensitivity analyses for different periods of observation. Findings: Neither the number of coercive measures used per month and bed nor their cumulative duration nor the number of assaults per bed and months differed significantly between the 27 intervention wards and the 27 control wards in the final 3 months of the intervention period. The median number of coercive measures used decreased by 45% (median 0.96 (IQR 1.34)-0.53 (IQR 0.59) from baseline until the end of the intervention period on the intervention wards and by 28% (median 0.98 (IQR 1.71)-0.71 (IQR 1.08) on waiting list wards. The PreVCo Rating Tool showed a significant improvement in intervention wards compared to control wards, indicating a successful implementation. Interpretation: The study demonstrated that guideline adherence could be significantly improved by the intervention. However, there was no evidence for an effect on the frequency or duration of coercive measures used. Spill-over effects and the impact of the COVID-19 pandemic on in-patient care might have limited the effect of the intervention. Further research from robust randomised controlled trials are necessary to identify effective interventions to reduce the use of coercion in psychiatric hospitals. Funding: The study was funded by the German Innovationsfonds beim Gemeinsamen Bundesausschuss (project no. 01VSF19037). The funder had no role in study design or data collection.

[Types of action orientation of primary nurses in building relationships with their patients in forensic psychiatric hospitals]. / Handlungsorientierungen Bezugspflegender in der Beziehungsgestaltung mit ihren Patient_innen im Maßregelvollzug.

Types of action orientation of primary nurses in building relationships with their patients in forensic psychiatric hospitals Abstract: Background: Building interpersonal relationships with patients is one of the most elementary tasks of mental health nurses in forensic psychiatric hospitals and should be considered as the core of their professional identity. The attitude of forensic psychiatric nurses has a substantial impact on building relationships even though this is often not immediately obvious as an implicit concept. Research question: Which types of action orientation of primary nurses characterize the building of relationships with their patients in forensic psychiatric hospitals? Methodology: To record the collective orientations of nurses, two group discussions were held with eight participants. The evaluation was carried out based on the documentary method. Results: Four types of orientations could be grouped into a generalizable basic typology. The focus is set on the relationship as a necessary precondition for successful cooperation with the patient. Honesty and mutual trust are significant features. Conversations about everyday topics facilitate relationship building. Openness and a genuine interest in the patient are equally as important as the definition and maintenance of personal boundaries. Conclusion: Implicit, action-oriented attitudes of forensic psychiatric nurses should be reflectively accessed in order to define professional relationships and maintain their boundaries. To achieve this, nurses need to have a structured framework to facilitate self-reflection and self-awareness. The goal is the systematic development of personal and interactional competences.

Implementation of guidelines on prevention of coercion and violence: baseline data of the randomized controlled PreVCo study.

Introduction: The PreVCo study examines whether a structured, operationalized implementation of guidelines to prevent coercion actually leads to fewer coercive measures on psychiatric wards. It is known from the literature that rates of coercive measures differ greatly between hospitals within a country. Studies on that topic also showed large Hawthorne effects. Therefore, it is important to collect valid baseline data for the comparison of similar wards and controlling for observer effects. Methods: Fifty five psychiatric wards in Germany treating voluntary and involuntary patients were randomly allocated to an intervention or a waiting list condition in matched pairs. As part of the randomized controlled trial, they completed a baseline survey. We collected data on admissions, occupied beds, involuntarily admitted cases, main diagnoses, the number and duration of coercive measures, assaults and staffing levels. We applied the PreVCo Rating Tool for each ward. The PreVCo Rating Tool is a fidelity rating, measuring the degree of implementation of 12 guideline-linked recommendations on Likert scales with a range of 0-135 points covering the main elements of the guidelines. Aggregated data on the ward level is provided, with no patient data provided. We performed a Wilcoxon signed-rank-test to compare intervention group and waiting list control group at baseline and to assess the success of randomization. Results: The participating wards had an average of 19.9% involuntarily admitted cases and a median 19 coercive measures per month (1 coercive measure per occupied bed, 0.5 per admission). The intervention group and waiting list group were not significantly different in these measurements. There were 6.0 assaults per month on average (0.3 assaults per occupied bed and 0.1 per admission). The PreVCo Rating Tool for guideline fidelity varied between 28 and 106 points. The percentage of involuntarily admitted cases showed a correlation with coercive measures per month and bed (Spearman's Rho = 0.56, p < 0.01). Discussion: Our findings that coercion varies widely within a country and mainly is associated with involuntarily admitted and aggressive patients are in line with the international literature. We believe that we included a sample that covers the scope of mental health care practice in Germany well.Clinical trial registration: www.isrctn.com, identifier ISRCTN71467851.

[DGPPN pilot study on the implementation of the S3 guideline "Prevention of coercion: prevention and therapy of aggressive behavior in adults"]. / DGPPN-Pilotstudie zur Implementierung der S3-Leitlinie "Verhinderung von Zwang: Prävention und Therapie aggressiven Verhaltens bei Erwachsenen".

OBJECTIVE: To investigate whether implementation recommendations derived from the German guidelines "Prevention of coercion" can be implemented on acute psychiatric wards by means of implementation consultants into ward work and if this contributes to an increased level of adherence to guideline intervention recommendations approved by the DGPPN (Deutsche Gesellschaft für Psychiatrie und Psychotherapie, Psychosomatik und Nervenheilkunde)? MATERIAL AND METHODS: Two medical or nursing experts advised ward teams on the implementation of three individually selected recommendations from the guidelines in a structured consulting process over 6 months. The degree of implementation of the recommendations was assessed before and after the intervention by the ward teams together with the implementation consultants using a tool developed for this purpose (PreVCo rating tool). RESULTS: A total of five wards responsible for compulsorily admitted patients took part in the pilot study; three of them completed the intervention. On all three wards, implementation of the guideline recommendations improved for both selected and unselected recommendations. The strategy of using implementation consultants as well as the application of the PreVCo rating tool were well accepted and considered feasible by both the treatment teams and the implementation consultants. CONCLUSION: This pilot study showed that an implementation of recommendations on psychiatric wards derived from the German guidelines "Prevention of coercion" supported by implementation consultants is feasible, well acceptable among treatment teams and can lead to positive changes. The sample of five wards with diverse patient profiles was convincing. The efficacy in terms of reduction of coercive measures is currently being investigated in a randomized controlled trial on 55 psychiatric wards in different parts of Germany, with an intervention based on this pilot study.

Individual and Needs-Based: The Platform-Model for Personnel Allocation in Child and Adolescent Psychiatry and Psychotherapy.

Objective: An initiative by scientific societies of psychiatry, child and adolescent psychiatry, psychosomatic medicine, and further associations established the Platform-Model for the development of a needs-based system for adequate personnel allocation in psychiatric inpatient and day clinic units. We present the development of the instrument and a pilot study to identify feasibility and limitations. Methods: The basis of the study was a threefold methodological approach. Paradigmatic case vignettes adequately reflecting symptomatology and circumstances were described and validated, working profiles were generated and validated, and a matrix representing different needs-based dimensions was developed. Through reference date surveys, patients were assigned to needs-based clusters and Psych-PV categories. The required treatment effort under consideration of guidelines or expert consensus was estimated in several rounds of expert panels (Delphi method). Results: The pilot study proves the feasibility of the Platform-Model. Methodological findings as well as limitations of the model were identified in order to further develop the Platform-Model. Conclusions: The Platform-Model cannot serve as a tool to describe clinical pathways, but it appears to be an adequate and practical tool for assessment of the required staffing level based on patient needs independent of diagnosis and setting.

Implementation of Guidelines on Prevention of Coercion and Violence (PreVCo) in Psychiatry: Study Protocol of a Randomized Controlled Trial (RCT).

BACKGROUND: Coercive measures are among the most controversial interventions in psychiatry. There is a large discrepancy between the sheer number of high-quality guidelines and the small number of scientifically accompanied initiatives to promote and evaluate their implementation into clinical routine. In Germany, an expert group developed guidelines to provide evidence- and consensus-based recommendations on how to deal with violence and coercion in psychiatry. METHODS: The study presented examines whether coercive measures on psychiatric wards can be reduced by means of an operationalized implementation of the guidelines "Prevention of coercion: prevention and therapy of aggressive behavior in adults". Out of a set of 12 interventions offered, wards are free to choose three interventions they want to implement. The primary outcome is the number of coercive measures per bed and month/year. Secondary outcomes are cumulative duration of coercive measures per bed and month/year. The most important control variable is the number of aggressive incidents. We plan to recruit 52 wards in Germany. Wards treating both voluntary and compulsorily admitted patients will be included. A 1:1 stratified randomized controlled trial will be conducted stratified by the amount of coercive measures and implemented aspects of the guidelines. In addition to the control group analysis, a waiting list design allows a pre-post analysis for all participating wards of the waiting list group. A parallel qualitative study will examine factors related to successful implementation and to successful reduction of coercion as well as relevant barriers. DISCUSSION: We are planning a nationwide study on the implementation of evidence- and consensus-based guidelines in psychiatric hospitals. This study intends to promote the transfer of expert knowledge as well as results from clinical trials into clinical routine with the potential to change supply structures in mental health sector. CLINICAL TRIAL REGISTRATION: www.isrctn.com, identifier ISRCTN71467851.

[Tasks and Activities of Nurses in Inpatient General Psychiatry - Results of a Delphi-Study]. / Aufgaben und Tätigkeiten der Pflege in der stationären Allgemeinpsychiatrie ­ Ergebnisse einer Delphi-Studie.

OBJECTIVES: To find a consensus of tasks and activities of nursing in inpatient general psychiatry. METHODS: Delphi survey for consensus finding with n = 235 (round 1) and n = 193 (round 2) experts of psychiatric nursing. RESULTS: Overall, a consensus based on expert opinion regarding the tasks and activities of nursing in inpatient general psychiatry, consisting of 79 items, was generated. CONCLUSIONS: Further research is needed regarding to the tasks and activities of nursing in special psychiatric and mental health settings and to the minimum qualification requirements of psychiatric nurses.

[Perspectives and Opportunities for Psychotherapeutic Interventions in Inpatient Psychiatric Treatment Delivered by Nurses]. / Perspektiven und Chancen für pflegerisch-psychotherapeutische Interventionen in der stationären psychiatrischen Behandlung.

BACKGROUND: Psychotherapy is an essential part of treating people with mental illness. However, the implementation of psychotherapeutic interventions in the field of inpatient psychiatric treatment remains well behind demand. At the same time, the use of psychotherapeutic interventions by other professional groups - such as social workers and nursing - is not a common practice in Germany. OBJECTIVE: What can we learn from the international research with regard to nursing for Germany in view of the insufficient supply of psychotherapeutic care. METHOD: Based on a literature analysis, the German situation of care is related to international developments and a German training curriculum is presented. RESULT: A look at the international literature shows that in other countries especially trained nurses perform psychotherapeutic Interventions. In addition, there are effective training curricula whose transferability to Germany appears to be possible after appropriate adjustments.An 18 months lasting training program for nurses is presented. In addition to disorder-specific competences, this curriculum also provides psychotherapeutic interventions with a general approach. CONCLUSION: Collaborative care in the collaboration of different health professionals has been repeatedly and stably proven to be effective and helpful in treating people with various mental disorders. In order to better meet the growing need for psychotherapeutic interventions in the population in the sense of a stepped care model, trained nurses need to be more involved in the provision of psychotherapeutic services.