Len Bowers

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 and meta‐analysis of the patient factors associated with psychiatric in‐patient aggression

To combine the results of earlier comparison studies of in‐patient aggression to quantitatively assess the strength of the association between patient factors and i) aggressive behaviour,ii) repetitive aggressive behaviour.

The antecedents of violence and aggression within psychiatric in-patient settings

Papadopoulos C, Ross J, Stewart D, Dack C, James K, Bowers L. The antecedents of violence and aggression within psychiatric in‐patient settings.

Safewards: a new model of conflict and containment on psychiatric wards

Accessible summary Rates of violence, self-harm, absconding and other incidents threatening patients and staff safety vary a great deal by hospital ward. Some wards have high rates, other low. The same goes for the actions of staff to prevent and contain such incidents, such as manual restraint, coerced medication, etc. The Safewards Model provides a simple and yet powerful explanation as to why these differences in rates occur. Six features of the inpatient psychiatric system have the capacity to give rise to flashpoints from which adverse incidents may follow. The Safewards Model makes it easy to generate ideas for changes that will make psychiatric wards safer for patients and staff. Abstract Conflict (aggression, self-harm, suicide, absconding, substance/alcohol use and medication refusal) and containment (as required medication, coerced intramuscular medication, seclusion, manual restraint, special observation, etc.) place patients and staff at risk of serious harm. The frequency of these events varies between wards, but there are few explanations as to why this is so, and a coherent model is lacking. This paper proposes a comprehensive explanatory model of these differences, and sketches the implications on methods for reducing risk and coercion in inpatient wards. This Safewards Model depicts six domains of originating factors: the staff team, the physical environment, outside hospital, the patient community, patient characteristics and the regulatory framework. These domains give risk to flashpoints, which have the capacity to trigger conflict and/or containment. Staff interventions can modify these processes by reducing the conflict-originating factors, preventing flashpoints from arising, cutting the link between flashpoint and conflict, choosing not to use containment, and ensuring that containment use does not lead to further conflict. We describe this model systematically and in detail, and show how this can be used to devise strategies for promoting the safety of patients and staff.

Psychiatric patients’ views on why their involuntary hospitalisation was right or wrong: a qualitative study

PurposeTo explore involuntary patients’ retrospective views on why their hospitalisation was right or wrong.MethodsInvoluntary patients were recruited from 22 hospitals in England and interviewed in-depth. The study drew on grounded theory and thematic analysis.ResultsMost of the patients felt mentally unwell before admission and out of control during their treatment. Despite these common experiences, three groups of patients with distinct views on their involuntary hospitalisation were identified: those who believed that it was right, those who thought it was wrong and those with ambivalent views. Those with retrospectively positive views believed that hospitalisation ensured that they received treatment, averted further harm and offered them the opportunity to recover in a safe place. They felt that coercion was necessary, as they could not recognise that they needed help when acutely unwell. Those who believed that involuntary admission was wrong thought that their problems could have been managed through less coercive interventions, and experienced hospitalisation as an unjust infringement of their autonomy, posing a permanent threat to their independence. Patients with ambivalent views believed that they needed acute treatment and that hospitalisation averted further harm. Nonetheless, they thought that their problems might have been managed through less coercive community interventions or a shorter voluntary hospitalisation.ConclusionsThe study illustrates why some patients view their involuntary hospitalisation positively, whereas others believe it was wrong. This knowledge could inform the development of interventions to improve patients’ views and treatment experiences.

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.