Alan Simpson

Identifying key factors associated with aggression on acute inpatient psychiatric wards.

Aggressive behaviour is a critical issue for modern acute psychiatric services, not just because of the adverse impact it has on patients and staff, but also because it puts a financial strain on service providers. The aim of this study was to assess the relationship of patient violence to other variables: patient characteristics, features of the service and physical environment, patient routines, staff factors, the use of containment methods, and other patient behaviours. A multivariate cross sectional design was utilised. Data were collected for a six month period on 136 acute psychiatric wards in 26 NHS Trusts in England. Multilevel modelling was conducted to ascertain those factors most strongly associated with verbal aggression, aggression toward objects, and physical aggression against others. High levels of aggression were associated with a high proportion of patients formally detained under mental health legislation, high patient turnover, alcohol use by patients, ward doors being locked, and higher staffing numbers (especially qualified nurses). The findings suggest that the imposition of restrictions on patients exacerbates the problem of violence, and that alcohol management strategies may be a productive intervention. Insufficient evidence is available to draw conclusions about the nature of the link between staffing numbers and violence.

Approval Ratings of Inpatient Coercive Interventions in a National Sample of Mental Health Service Users and Staff in England

OBJECTIVE This study sought to ascertain the degree to which psychiatric inpatients and staff approved of various coercive measures commonly used in acute inpatient care. METHODS A cross-sectional design was adopted. The Attitudes to Containment Measures Questionnaire (ACMQ) was completed by 1,361 service users and 1,226 staff (68% nurses) in acute care mental health services from three regions of England. This provided evaluation of 11 coercive measures (for example, seclusion) on six dimensions of approval (for example, whether the coercive measure is seen as being acceptable or safe to use) in a large national sample. Comparisons between groups were tested with independent-samples t tests, chi square analysis, or Spearman correlations. RESULTS Service users and staff strongly disapproved of net beds and mechanical restraint. The three methods that received the most approval by the service user group were intermittent observation, time out, and PRN (as needed) medication; for the staff group, the three methods that were most approved of were transfer to a psychiatric intensive care unit, PRN medication, and observation. Male staff, older service users, and staff who had been involved in implementing coercion expressed greater approval of coercive measures. CONCLUSIONS There are clear gender differences in how coercive measures that are used in inpatient settings are viewed. Personal involvement in deploying coercive interventions was linked to greater acceptance, suggesting a link between experience and attitudinal changes.

A Review of Interventions to Reduce Mechanical Restraint and Seclusion among Adult Psychiatric Inpatients

This review examines the nature and effectiveness of interventions to reduce the use of mechanical restraint and seclusion among adult psychiatric inpatients. Thirty-six post-1960 empirical studies were identified. The interventions were diverse, but commonly included new restraint or seclusion policies, staffing changes, staff training, case review procedures, or crisis management initiatives. Most studies reported reduced levels of mechanical restraint and/or seclusion, but the standard of evidence was poor. The research did not address which programme components were most successful. More attention should be paid to understanding how interventions work, particularly from the perspective of nursing staff, an issue that is largely overlooked.

The nature and purpose of acute psychiatric wards : The tompkins acute ward study

Background: Acute inpatient care in the UK is being subjected to increasing critical scrutiny, highlighting concerns about content and quality. There is an absence of clarity and consensus on what acute inpatient care is for, adding to difficulties in developing this service sector. Aim: To define the function of acute psychiatric wards. Methods: Interviews were conducted with multidisciplinary staff (13 Ward Managers, 14 F Grade nurses, 11 Occupational Therapists and 9 Consultant Psychiatrists), on rationales for admission, their care and treatment philosophy, and the roles of different professionals. Results: Patients are admitted because they appear likely to harm themselves or others, and because they are suffering from a severe mental illness, and/or because they or their family/community require respite, and/or because they have insufficient support and supervision available to them in the community. The tasks of acute inpatient care are to keep patients safe, assess their problems, treat their mental illness, meet their basic care needs and provide physical healthcare. These tasks are completed via containment, 24-hour staff presence, treatment provision, and complex organisation and management. Conclusions: Professional education, audit, research and the structuring of services all need to be oriented towards these tasks. Declaration of interest: This study was funded by the Tompkins Foundation and the Department of Health Nursing Quality initiative.

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 5.6–23.7%) relative to the control intervention. The rate of containment events for the experimental intervention was reduced by 26.4% (95% CI 9.9–34.3%). Conclusions Simple interventions aiming to improve staff relationships with patients can reduce the frequency of conflict and containment. Trial registration IRSCTN38001825.

Coerced medication in psychiatric inpatient care: literature review

AIM This paper is a report of a narrative review of the coercive use of medication in inpatient psychiatric care to identify a demographic and clinical profile of patients who are forcibly medicated, and to examine patient and staff views of this practice. BACKGROUND Lack of compliance with medication is associated with quicker relapse and increased risk to self and others in mental disorder. It is this increased risk which provides the ethical and legal grounds for detaining and treating psychiatric patients without their consent. Legislation for involuntary psychiatric treatment exists in all European Union member states and in other western countries. DATA SOURCES Online bibliographic databases from 1980 to 2008 were searched, including British Nursing Index, CINAHL, PsycINFO, EMBASE and MEDLINE. Search terms relating to coercion, force, chemical restraint, rapid tranquilization, inpatients and psychiatry were used. REVIEW METHODS Titles and abstracts were reviewed. All peer reviewed papers concerning coercion in the administration of medication in inpatient psychiatric care were included and a narrative review was conducted. RESULTS Fourteen papers from seven countries were included. Patients who have experience coerced medication tend to be aged in their 30s, with a diagnosis of schizophrenia, bipolar or other psychotic disorders, and are often involuntarily admitted. Assault or threat of assault is the main reason for giving forced medication. CONCLUSION There is a dearth of literature in the area of coercion in administration of medication and much more research is needed examining all aspects of this contentious practice.

Patient-staff conflict: results of a survey on acute psychiatric wards

Abstract.Background: Disruptive behaviours of acute psychiatric inpatients have typically been studied separately, as have the methods used to contain them. There are indications that behaviours and containment methods are systematically related. Aims: The aim of this study was to assess the frequency and relationship between the differing conflict behaviours of patients, and explore the relationship between professional containment measures and those conflict behaviours. Methods: A cross-sectional survey of conflict behaviours and containment of 238 two-week admissions to 12 acute psychiatric wards in London, UK was carried out. Results: Factor analysis revealed seven patterns of conflict behaviours, with aggression being separately associated with absconding and medication refusal. Neither substance misuse nor self-harm were associated with aggression. Aggressive behaviour attracted the widest range of containment measures, including the use of special observation. Conclusions: The conflict behaviours of patients form complex patterns, and should be studied together rather than separately.

Adverse incidents, patient flow and nursing workforce variables on acute psychiatric wards : The tompkins acute ward study

Background: Adverse incidents (violence, self-harm and absconding) can cause significant harm to patients and staff, are difficult to predict, and are driving an increase in security measures and defensive practice. Aims: To explore the relationship between adverse incidents on acute psychiatric wards, admissions and nursing workforce variables. Methods: A retrospective analysis of officially collected data covering a period of 30 months on 14 acute wards at three hospitals. This data included 69 serious untoward incidents. Results: Adverse incidents were more likely during and after weeks of high numbers of male admissions, during weeks when other incidents also occurred, and during weeks of high regular staff absence through leave and vacancy. Conclusions: It may be possible to predict adverse incidents. Careful staff management and deployment may reduce the risks.

The relationship between leadership, teamworking, structure, burnout and attitude to patients on acute psychiatric wards

BackgroundConflict (aggression, substance use, absconding, etc.) and containment (coerced medication, manual restraint, etc.) threaten the safety of patients and staff on psychiatric wards. Previous work has suggested that staff variables may be significant in explaining differences between wards in their rates of these behaviours, and that structure (ward organisation, rules and daily routines) might be the most critical of these. This paper describes the exploration of a large dataset to assess the relationship between structure and other staff variables.MethodsA multivariate cross-sectional design was utilised. Data were collected from staff on 136 acute psychiatric wards in 26 NHS Trusts in England, measuring leadership, teamwork, structure, burnout and attitudes towards difficult patients. Relationships between these variables were explored through principal components analysis (PCA), structural equation modelling and cluster analysis.ResultsPrincipal components analysis resulted in the identification of each questionnaire as a separate factor, indicating that the selected instruments assessed a number of non-overlapping items relevant for ward functioning. Structural equation modelling suggested a linear model in which leadership influenced teamwork, teamwork structure; structure burnout; and burnout feelings about difficult patients. Finally, cluster analysis identified two significantly distinct groups of wards: the larger of which had particularly good leadership, teamwork, structure, attitudes towards patients and low burnout; and the second smaller proportion which was poor on all variables and high on burnout. The better functioning cluster of wards had significantly lower rates of containment events.ConclusionThe overall performance of staff teams is associated with differing rates of containment on wards. Interventions to reduce rates of containment on wards may need to address staff issues at every level, from leadership through to staff attitudes.

Relationship between service ecology, special observation and self-harm during acute in-patient care: City-128 study

BACKGROUND Special observation (the allocation of nurses to watch over nominated patients) is one means by which psychiatric services endeavour to keep in-patients safe from harm. The practice is both contentious and of unknown efficacy. AIMS To assess the relationship between special observation and self-harm rates, by ward, while controlling for potential confounding variables. METHOD A multivariate cross-sectional study collecting data on self-harm, special observation, other conflict and containment, physical environment, patient and staff factors for a 6-month period on 136 acute-admission psychiatric wards. RESULTS Constant special observation was not associated with self-harm rates, but intermittent observation was associated with reduced self-harm, as were levels of qualified nursing staff and more intense programmes of patient activities. CONCLUSIONS Certain features of nursing deployment and activity may serve to protect patients. The efficacy of constant special observation remains open to question.