Teresa Allan

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.

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.

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.

The relationship between continuing professional education and commitment to nursing

Nurses have a responsibility to undertake continuing professional development to enable them to keep abreast with changes in health care. Acquiring new knowledge and skills is essential for nurses to practice safely in new and extended roles. Opportunities for continuing professional development are thought to increase retention. The aim of this study was to explore the relationship between undertaking continuing professional development and commitment to the profession and the employing National Health Service trust and to explore any differences between nurses in standard and extended roles. A questionnaire survey was undertaken with 451 nurses employed in three contrasting trusts. The questionnaire incorporated a validated scale to measure organisational and professional commitment. Three hundred and eighteen (70.5%) of the nurses had undertaken continuing professional development over the previous 12 months. Ninety nine nurses (22%) had received only mandatory training over the same period. There was no evidence of a relationship between professional and organisational commitment and undertaking continuing professional development. There was no evidence that specialist nurses in extended roles had undertaken the developmental continuing professional development that would be expected in order for them to acquire new competencies and skills.

Morale is high in acute inpatient psychiatry.

BackgroundMorale on acute psychiatric wards has been considered to be problematic, and is reported to contribute to low quality patient care. Aim: To assess the relationship of staff morale to patient, service environment, physical environment, patient routines, conflict, containment, staff demographics, and staff group variables.MethodA multivariate cross sectional study was undertaken collecting data on morale, as measured by the Maslach Burnout Inventory, and other variables on 136 acute admission psychiatric wards in England.ResultsMorale was higher than published comparison samples. Length of time in post was correlated with low morale, and qualified nurses had higher emotional exhaustion but also higher personal accomplishment. The level of verbal abuse on a ward was associated with low morale, as was a higher level of social deprivation among patients. Higher levels of order and organisation correlated with better morale.ConclusionsClear policies relating to the management of verbal abuse by patients, high levels of order and organisation, and staff rotation and education, may all support high morale. Acute inpatient psychiatry is generally a happy and rewarding work environment, and identified problems are likely to be due to other factors.

Using a Group Approach to Preventing Heroin Overdose in North London.

Aims: This study used group psycho-education methods to assist injecting heroin users in preventing, and responding to overdose. Methods: An ‘OD Prevention’ group was advertised in a London prescribing service and associated primary care unit. The intervention took place in a small group over one afternoon (3.5 hours), and trained participants in recognizing, and responding to heroin overdoses (defining overdose, discussing known risk factors and on-site instruction in cardio-pulmonary resuscitation (CPR). Participants were all injecting heroin users in service contact with the primary care unit, drug dependence unit, or hostels for the homeless in central London. Participants self-referred, or were referred by key workers. Participants completed pre- and post-group questionnaires concerning their personal experience of overdose, the witnessing of others’ overdoses and fatalities, their current response in overdose situations, and their overall confidence in helping others who have overdosed. Findings: In total 107 people attended the group. Of these, 42% had witnessed others’ overdose, and 29% had witnessed one or more deaths as a result of overdose. Following the group intervention more participants reported feeling ‘quite or very confident’ in managing an OD situation, confident in undertaking CPR with someone who had overdosed, and were less likely to pursue ‘folklore’ remedies to overdose. Conclusions: Using psycho-educational group approaches can be an effective tool in attempts to prevent and respond to heroin overdoses, and is seen as useful by users.