The assessment and management of the violent patient in critical hospital settings

Situational Factors Impacting Harmful Behavior Towards Others Related to Mental Health in the Community and Their Associations: A Scoping Review Based on Systematic Reviews

BACKGROUND/OBJECTIVES

This study aimed to identify factors associated with harmful behavior toward others based on existing research.

METHODS

This scoping review focused on individuals at risk of harming others due to mental health issues, with the target population encompassing three settings: the community, inpatient facilities with frequent admissions and discharges, and healthcare settings where medical treatment is sought. A scoping review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. The terms violence, aggression, problem behavior, and workplace violence were used to search for related literature, subsequently selecting systematic reviews.

RESULTS

A total of 24 papers were ultimately included. From the included papers, background factors (demographic, personal history, and clinical aspects); situational factors (social connection status, daily life status); psychological factors; antecedents of harmful behavior; and triggers of harmful behavior were extracted as factors associated with harmful behavior.

CONCLUSIONS

Our results indicate that background and situational factors lead to harmful behavior toward others, disruptions in the harmony between these factors cause disturbances in psychological processes, and harmful behavior toward others is triggered by stimuli that promote such behavior. Considering that all studies reviewed herein involved inpatients and forensic patients in medical settings, further research is required to identify the factors associated with harmful behaviors occurring in the community.

Measures and narratives of the nature, causes and consequences of violent assaults and risk perception of psychiatric hospitals in Ghana: Mental Health workers' perspectives

Literature shows that mental healthcare workers in Ghana face incessant fear of patient violence that compromise safe care delivery. However, the nature, scale, perceived causes, and consequences of these assaults and how they shape risk perceptions have received limited empirical attention, hence the need for this study. The study employed sequential explanatory mixed methods where questionnaire administration preceded and informed the design of an interview guide used for in-depth interviews with health workers in referral psychiatric hospitals. Descriptive statistics and multivariate logistic regressions were used to analyze the quantitative data. Qualitative data were transcribed and analyzed thematically. Findings showed that physical and non-physical violent assaults and risk perceptions of the hospitals were statistically and significantly associated with females (P < 0.01), nurses (P < 0.01), other clinical cadre (P < 0.01), and those with low job tenure (P < 0.05). About 57% and 71% of the sample reported experiencing physical and non-physical assaults, respectively. Major and minor injuries and psychosocial problems were frequent sequelae following physical violent assaults. As a result, 80% of the participants perceived the hospitals environment to be unsafe to provide care. Violent assaults compromises safety and care delivery efforts suggesting the need for systematic interventions to minimize mental healthcare workers exposure to patient violence.

Management of the aggressive emergency department patient: non-pharmacological perspectives and evidence base

INTRODUCTION

Aggression in the Emergency Department (ED) remains an ongoing issue, described as reaching epidemic proportions, with an impact on staff recruitment, retention, and ability to provide quality care. Most literature has focused on the definition (or lack of) core concepts, efforts to quantify the phenomenon or provide an epidemiological profile. Relatively little offers evidence-based interventions or evaluations of the same.

AIM

To identify the range of suggested practices and the evidence base for currently recommended actions relating to the management of the aggressive Emergency Department patient.

METHODS

A meta-synthesis of existing reviews of violence and aggression in the acute health-care setting, including management of the aggressive patient, was undertaken. This provided the context for critical consideration of the management of this patient group in the ED and implications for clinical practice.

RESULTS

An initial outline of issues was followed by a systematic search and 15 reviews were further assessed. Commonly identified interventions are grouped around educational, interpersonal, environmental, and physical responses. These actions can be focused in terms of overall responses to the wider issues of violence and aggression, targeted at the pre-event, event, or post-event phase in terms of strategies; however, there is a very limited evidence base to show the effectiveness of strategies suggested.

CLINICAL IMPLICATIONS

The lack of evidence-based intervention strategies leaves clinicians in a difficult situation, often enacting practices based on anecdote rather than evidence. Local solutions to local problems are occurring in a pragmatic manner, but there needs to be clarification and integration of workable processes for evaluating and disseminating best practice.

CONCLUSION

There is limited evidence reporting on interventional studies, in addition to identification of the need for high quality longitudinal and evaluation studies to determine the efficacy of those responses that have been identified.

Effect of an educational training intervention on rapid tranquillisation usage – a pilot nursing study in a public hospital in Singapore

Background:

Studies evaluating nursing educational initiatives in rapid tranquillisation procedures are lacking.

Objective:

This pilot study in a public hospital in Singapore evaluated the effect of an educational training intervention on knowledge and confidence of nurses using rapid tranquillisation in two medical wards.

Method:

The study design was a pilot pre- and post-test single-group design on a voluntary sample of 75 nurses. The educational training intervention comprised of a 60 min interactive presentation followed by a small-group-based case discussion conducted by an advanced nurse practitioner. Knowledge was measured using a ‘test the knowledge’ questionnaire; a Likert scale measured perceived level of confidence.

Results:

The knowledge score (overall score = 11) was significantly improved from pre-training (average score: 5.1 (standard deviation, 1.3)) to post-training (average score: 8.1 (standard deviation, 1.8)), t = −12.61, p < 0.001. The participants were more confident after training ( p < 0.001).

Conclusion:

This study has shown that a classroom training intervention of nurses in rapid tranquillisation procedures improved knowledge and confidence in dealing with patient violence in hospitals and added to the safe practice of rapid tranquillisation. Further studies evaluating the long-term and clinical impact of training with more rigorous study designs are needed to replicate these promising findings.

Duty, Empathy, and Hierarchy: Healing "Difficult Patients"

Anthony is a fourth-year medical student, currently on service during an away surgery rotation. He is rounding with a first-year intern, Dr. Lovett, and the attending, Dr. Todd. They stop outside the room of Mr. Turpin, a 54-year-old male who has recently had a toe amputation due to uncontrolled diabetes mellitus. His chart lists him as a drug-seeker managed for chronic pain. As such, his analgesics are being closely monitored. Before entering the room, Dr. Lovett mentions that the patient had been irritated the night prior, complaining of uncontrolled pain, and upset at staff for refusing increased pain medication. Dr. Todd knows this, remarking that Mr. Turpin has a history of being a "difficult patient."

Implementation of the Brøset Violence Checklist on an Acute Psychiatric Unit

BACKGROUND: Violence on inpatient psychiatric settings has significant consequences for patients and staff. Research is needed to determine if Brøset Violence Checklist (BVC) is an accurate predictor of violence. AIMS: The study aims were to determine the relationship between BVC scores and incidence of violent behavior within 24 hours, to compare scores among those requiring high-level nursing interventions for violence, and to investigate the impact of scores on length of stay (LOS) and 30 day-readmission rates. METHOD: Retrospective cohort study. RESULTS: Logistic regression indicates 3.4 times greater risk of violence for every additional point on admission BVC (odds ratio = 3.4, 95% confidence interval = [2.29, 5.08], p < .0001). Patients requiring high-level interventions for violence had higher mean BVC scores on both Day 1 and 2 of admission. Pearson correlation was significant for positive association between BVC on admission and LOS (p < .001). Findings did not establish a link between BVC scores and violence with 30-day readmission rates. CONCLUSIONS: Efforts toward early identification and management of agitation and disruptive behavior is encouraged. Results showed increased risk of violence with every additional point on BVC on admission; further attention should be paid to these patients on admission when using violence screening tools.

Predictive validity and gender differences in a biopsychosocial model of violence risk assessment in acute psychiatry

Current violence risk assessment methods seem to have reached an upper limit of accuracy. More comprehensive biopsychosocial models may improve on existing methods. Research on gender differences concerning risk factors of violence is scarce and inconclusive. In this prospective study from an acute psychiatric ward, all patients admitted from March 2012 to March 2013 were included. Predictive validity and potential gender differences in a biopsychosocial model of violence risk assessment consisting of a psychosocial checklist (Violence risk screening-10, V-RISK-10), a patient's self-report risk scale (SRS), total cholesterol (TC) and high-density lipoprotein cholesterol (HDL) were examined in an inpatient (N = 348) and a 3-months follow-up (N = 101) sample. Overall increases in explained variances and predictive values were small and non-significant compared to V-RISK-10 alone. In the inpatient sample, HDL contributed significantly to the model for men but not for women. In the follow-up sample, SRS contributed significantly for the whole sample. Results indicated that the biopsychosocial model we tested partially improved accuracy of violence risk assessments in acute psychiatry and that gender differences may exist.

Rates of workplace aggression in the emergency department and nurses' perceptions of this challenging behaviour: A multimethod study

INTRODUCTION

Over the last 10 years, the rate of people presenting with challenging behaviour to emergency departments (EDs) has increased and is recognised as a frequent occurrence facing clinicians today. Challenging behaviour often includes verbal aggression, physical aggression, intimidation and destruction of property.

AIM

The aim of this research was to (i) identify the characteristics and patterns of ED-reported incidents of challenging behaviour and (ii) explore emergency nurses' perceptions of caring for patients displaying challenging behaviour.

METHODS

This was a multi-method study conducted across two metropolitan Sydney district hospitals. Phase 1 involved a 12-month review of the hospital's incident management database. Phase 2 involved a survey of emergency nurses' perceptions of caring for patients displaying challenging behaviour.

RESULTS

Over 12 months there were 34 incidents of aggression documented and the perpetrators were often male (n=18; 53.0%). The average age was 34.5 years. The majority of reported incidents (n=33; 90.1%) involved intimidation, verbal assault and threatening behaviour. The median time between patient arrival and incident was 109.5min (IQR 192min). The median length of stay for patients was 302.5min (IQR 479min). There was no statistical difference between day of arrival and time of actual incident (t-test p=0.235), length of stay (t-test p=0.963) or ED arrival to incident time (t-test p=0.337). The survey (n=53; 66.2%) identified the average ED experience was 12.2 years (SD 9.8 years). All participants surveyed had experienced verbal abuse and/or physical abuse. Participants (n=52) ranked being spat at (n=37; 71.1%) the most difficult to manage. Qualitative survey open-ended comments were analysed and organised thematically.

THEMATIC ANALYSIS

The survey identified three themes which were (i) increasing security, (ii) open access and (iii) rostering imbalance.

CONCLUSION

The study provides insight into emergency nurses' reported perceptions of patients who display challenging behaviour. All emergency nurse participants reported being regularly exposed to challenging behaviour and this involved both physical and verbal abuse. This was in contrast to a low incident hospital reporting rate. ED clinicians need to be better supported with targeted educational programmes, appropriate ED architecture and reporting mechanism that are not onerous.