Ian Needham

Structured risk assessment and violence in acute psychiatric wards: randomised controlled trial

BACKGROUND There is a lack of research on the possible contribution of a structured risk assessment to the reduction of aggression in psychiatric in-patient care. AIMS To assess whether such risk assessments decrease the incidence of violence and coercion. METHOD A cluster randomised controlled trial was conducted with 14 acute psychiatric admission wards as the units of randomisation, including a preference arm. The intervention comprised a standardised risk assessment following admission with mandatory evaluation of prevention in high-risk patients. RESULTS Incidence rates decreased substantially in the intervention wards, whereas little change occurred in the control wards. The adjusted risk ratios suggest a 41% reduction in severe aggressive incidents and a 27% decline in the use of coercive measures. The severity of aggressive incidents did not decrease. CONCLUSIONS Structured risk assessment during the first days of treatment may contribute to reduced violence and coercion in acute psychiatric wards.

Perception of aggression among psychiatric nurses in Switzerland

Objective:  To identify principal components and patterns in the perception of aggression by psychiatric nurses and to explore relationships between the perception of aggression and personal and workplace characteristics.

Predicting inpatient violence using an extended version of the Broset-Violence-Checklist: instrument development and clinical application.

BackgroundPatient aggression is a common problem in acute psychiatric wards and calls for preventive measures. The timely use of preventive measures presupposes a preceded risk assessment. The Norwegian Brøset-Violence-Checklist (BVC) is one of the few instruments suited for short-time prediction of violence of psychiatric inpatients in routine care. Aims of our study were to improve the accuracy of the short-term prediction of violence in acute inpatient settings by combining the Brøset-Violence-Checklist (BVC) with an overall subjective clinical risk-assessment and to test the application of the combined measure in daily practice.MethodWe conducted a prospective cohort study with two samples of newly admitted psychiatric patients for instrument development (219 patients) and clinical application (300 patients). Risk of physical attacks was assessed by combining the 6-item BVC and a 6-point score derived from a Visual Analog Scale. Incidents were registered with the Staff Observation of Aggression Scale-Revised SOAS-R. Test accuracy was described as the area under the receiver operating characteristic curve (AUCROC).ResultsThe AUCROC of the new VAS-complemented BVC-version (BVC-VAS) was 0.95 in and 0.89 in the derivation and validation study respectively.ConclusionThe BVC-VAS is an easy to use and accurate instrument for systematic short-term prediction of violent attacks in acute psychiatric wards. The inclusion of the VAS-derived data did not change the accuracy of the original BVC.

Development of an instrument to measure the quality of documented nursing diagnoses, interventions and outcomes: the Q-DIO.

AIMS AND OBJECTIVES This paper aims to report the development stages of an audit instrument to assess standardised nursing language. Because research-based instruments were not available, the instrument Quality of documentation of nursing Diagnoses, Interventions and Outcomes (Q-DIO) was developed. BACKGROUND Standardised nursing language such as nursing diagnoses, interventions and outcomes are being implemented worldwide and will be crucial for the electronic health record. The literature showed a lack of audit instruments to assess the quality of standardised nursing language in nursing documentation. DESIGN A qualitative design was used for instrument development. METHODS Criteria were first derived from a theoretical framework and literature reviews. Second, the criteria were operationalized into items and eight experts assessed face and content validity of the Q-DIO. RESULTS Criteria were developed and operationalized into 29 items. For each item, a three or five point scale was applied. The experts supported content validity and showed 88.25% agreement for the scores assigned to the 29 items of the Q-DIO. CONCLUSIONS The Q-DIO provides a literature-based audit instrument for nursing documentation. The strength of Q-DIO is its ability to measure the quality of nursing diagnoses and related interventions and nursing-sensitive patient outcomes. Further testing of Q-DIO is recommended. RELEVANCE TO CLINICAL PRACTICE Based on the results of this study, the Q-DIO provides an audit instrument to be used in clinical practice. Its criteria can set the stage for the electronic nursing documentation in electronic health records.

Testing the Q‐DIO as an Instrument to Measure the Documented Quality of Nursing Diagnoses, Interventions, and Outcomes

PURPOSE To describe pilot testing of Quality of Diagnoses, Interventions and Outcomes (Q-DIO), an instrument to measure quality of nursing documentation. DESIGN Instrument testing was performed using a random, stratified sample of 60 nursing documentations representing hospital nursing with and without implementation of standardized nursing language (30 for both strata) in a Swiss General Acute Hospital. METHODS Internal consistency and intrarater and interrater reliabilities were tested. Through item analyses, the grades of difficulty and the discrimination validity of items were evaluated. FINDINGS Internal consistency of nursing diagnoses as process produced Cronbachs alpha .83; nursing diagnoses as product .98; nursing interventions .90; and nursing-sensitive patient outcomes .99. With Kappas of .95, the intrarater and interrater reliabilities were good. Criteria for the grades of difficulty of items and discrimination validity were well met. The results of this study suggest that Q-DIO is a reliable instrument to measure the documentation quality of nursing diagnoses, interventions, and outcomes. Further testing of Q-DIO in other settings is recommended.

The Effects of Aggression Management Training for Mental Health Care and Disability Care Staff: A Systematic Review

BACKGROUND Aggression management trainings for staff have been implemented in many organizations of mental health care and disability care. The efficacy of such programmes has rarely been analysed. METHODS A systematic review was conducted which contains all published evaluation studies on aggression management trainings. Inclusion criteria were before-and-after-comparisons or control group designs. RESULTS 39 published studies were included. Study quality has to be regarded as low. Concerning the results of the studies, no clear trend emerged in direction of minimising violent incidents. However, studies revealed clear positive effects on knowledge about violence and on staffs confidence to cope with difficult situations. CONCLUSIONS Sensitisation effects in staff after getting trained probably lead to reporting bias. Although the results on the number of violent incidents remain unclear, it is recommended to conduct comprehensive aggression management trainings in mental health and disability care institutions.

Vocally disruptive behavior in the elderly: a systematic review.

BACKGROUND Vocally disruptive behavior (VDB) in the elderly is a common condition, especially in people with dementia, but difficult to treat. It may occur in as many as 40% of nursing home residents. This study is a review of the existing literature on this condition. METHOD The literature review was conducted using PubMed (particularly Medline and the Cochrane database) and reference lists from relevant publications in English, French, and German. RESULTS Most studies are small and no conclusive prevalence data are available. Many biological and psychosocial treatments have been advocated, but most studies are little more than anecdotal case reports. It is evident that VDB can have deleterious consequences on others and the patients themselves, although no studies specifically examine the range or the pervasiveness of VDB. Etiopathogenic research on VDB is still in its infancy. CONCLUSIONS Most aspects surrounding VDB are insufficiently understood. The heterogeneity and multiple contributive factors regarding VDB suggest quite convincingly that a panoply of different interventions tailored to the individuals needs will be required to overcome VDB and the suffering related to it.

Pflegediagnosen, -interventionen und -ergebnisse: Anwendung und Auswirkungen auf die Pflegepraxis: Eine systematische Literaturübersicht.

Dieser Artikel beschreibt eine systematische Literaturubersicht zu den Auswirkungen der Pflegediagnostik. Es werden Auswirkungen auf die Qualitat des Pflegeassessments sowie auf die Haufigkeit, Genauigkeit und Vollstandigkeit von Pflegediagnosen und auf die Koharenz zwischen Pflegediagnosen, -interventionen und -ergebnissen aufgezeigt, wie sie in Patientenakten2 dokumentiert werden. Steigende Kosten machen es erforderlich, den Beitrag der Pflege zur Gesundheitsversorgung zu bestimmen. Dies wird durch den Einsatz standardisierter Terminologien erleichtert. Zwar liegen Studien vor, in denen eine standardisierte Dokumentation von Pflegediagnosen und ihre Beziehung zu Pflegeinterventionen und Pflegergebnissen evaluiert wurden, eine systematische Ubersicht fehlte jedoch bislang. Es wurde eine Suche in MEDLINE, CINAHL und der Cochrane Database (1982–2004) durchgefuhrt und durch Grundlagenartikel und Tagungsberichte erweitert. Einschlusskriterien wurden bestimmt und umgesetzt. Anschliesend sind sechsunddreisig A...

Nursing phenomena in inpatient psychiatry

Little is known about the question if the nursing diagnosis classification of North American Nursing Association-International (NANDA-I) describes the adult inpatient psychiatric nursing care. The present study aimed to identify nursing phenomena mentioned in journal articles about the psychiatric inpatient nursing care and to compare these phenomena with the labels and the definitions of the nursing diagnoses to elucidate how well this classification covers these phenomena. A search of journal articles took place in the databases MedLine, PsychInfo, Cochrane and CINAHL. A qualitative content analysis approach was used to identify nursing phenomena in the articles. Various phenomena were found in the articles. The study demonstrated that NANDA-I describes essential phenomena for the adult inpatient psychiatry on the level of labels and definitions. However, some apparently important nursing phenomena are not covered by the labels or definitions of NANDA-I. Other phenomena are assigned as defining characteristics or as related factors to construct nursing diagnoses. The further development of the classification NANDA-I will strengthen the application in the daily work of psychiatric nurses and enhance the quality of nursing care in the inpatient setting.

Ward safety perceived by ward managers in Britain, Germany and Switzerland: identifying factors that improve ability to deal with violence.

Little is known about how safe nurses feel on psychiatric wards across different European countries. This paper is aim to evaluate how ward safety is perceived by ward managers in Great Britain, Germany and Switzerland. We replicated a Swiss questionnaire study in Germany and Britain, which asked ward managers on adult psychiatric wards to give details about their ward including data on the management of aggression, staffing levels, staff training, standards and type of restraint used, alarm devices, treatment and management of aggression and the existence and perceived efficacy of standards (protocols, guidelines). The British sample had by far the highest staffing levels per psychiatric bed, followed by Switzerland and Germany. The British ward managers by far perceived violence and aggression least as a problem on their wards, followed by Germany and then Switzerland. British ward managers are most satisfied with risk management and current practice dealing with violence. German managers were most likely to use fixation and most likely to have specific documentation for coercive measures. Swiss wards were most likely to use non-specific bedrooms for seclusion and carry alarm devices. British wards were far more likely to have protocols and training for the treatment and management of violence, followed by Switzerland and Germany. British ward managers by far perceived violence and aggression to be a small problem on their wards compared with Swiss and German ward managers. This was associated with the availability of control and restraint teams, regular training, clear protocols and a lesser degree risk assessments, but not staffing levels.