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Välimäki M, Lantta T, Kontio R. Risk assessment for aggressive behaviour in schizophrenia. Cochrane Database Syst Rev 2024; 5:CD012397. [PMID: 38695777 PMCID: PMC11064887 DOI: 10.1002/14651858.cd012397.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
BACKGROUND Aggressive or violent behaviour is often associated with people with schizophrenia in common perceptions of the disease. Risk assessment methods have been used to identify and evaluate the behaviour of those individuals who are at the greatest risk of perpetrating aggression or violence or characterise the likelihood to commit acts. Although many different interventions have been developed to decrease aggressive or violent incidences in inpatient care, staff working in inpatient settings seek easy-to-use methods to decrease patient aggressive events. However, many of these are time-consuming, and they require intensive training for staff and patient monitoring. It has also been recognised in clinical practice that if staff monitor patients' behaviour in a structured manner, the monitoring itself may result in a reduction of aggressive/violent behaviour and incidents in psychiatric settings. OBJECTIVES To assess the effects of structured aggression or violence risk assessment methods for people with schizophrenia or schizophrenia-like illnesses. SEARCH METHODS We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials, which is based on CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PubMed, ISRCTN registry, ClinicalTrials.gov, and WHO ICTRP, on 10 February 2021. We also inspected references of all identified studies. SELECTION CRITERIA We included all randomised controlled trials (RCTs) comparing structured risk assessment methods added to standard professional care with standard professional care for the evaluation of aggressive or violent behaviour among people with schizophrenia. DATA COLLECTION AND ANALYSIS At least two review authors independently inspected citations, selected studies, extracted data, and appraised study quality. For binary outcomes, we calculated a standard estimation of the risk ratio (RR) and its 95% confidence interval (CI). For continuous outcomes, we calculated the mean difference (MD) and its 95% CI. We assessed risk of bias in the included studies and created a summary of findings table using the GRADE approach. MAIN RESULTS We included four studies in the review. The total number of participants was not identifiable, as some studies provided number of participants included, and some only patient days. The studies compared a package of structured assessment methods with a control group that included routine nursing care and drug therapy or unstructured psychiatric observations/treatment based on clinical judgement. In two studies, information about treatment in control care was not available. One study reported results for our primary outcome, clinically important change in aggressive/violent behaviour, measured by the rate of severe aggression events. There was likely a positive effect favouring structured risk assessment over standard professional care (RR 0.59, 95% CI 0.41 to 0.85; 1 RCT; 1852 participants; corrected for cluster design: RR 0.59, 95% CI 0.37 to 0.93; moderate-certainty evidence). One trial reported data for the use of coercive measures (seclusion room). Compared to standard professional care, structured risk assessment may have little or no effect on use of seclusion room as days (corrected for cluster design: RR 0.92, 95% CI 0.27 to 3.07; N = 20; low-certainty evidence) or use of seclusion room as secluded participants (RR 1.83, 95% CI 0.39 to 8.7; 1 RCT; N = 20; low-certainty evidence). However, seclusion room may be used less frequently in the standard professional care group compared to the structured risk assessment group (incidence) (corrected for cluster design: RR 1.63, 95% CI 0.49 to 5.47; 1 RCT; N = 20; substantial heterogeneity, Chi2 = 0.0; df = 0.0; P = 0.0; I2 = 100%; low-certainty evidence). There was no evidence of a clear effect on adverse events of escape (RR 0.2, 95% CI 0.01 to 4.11; 1 RCT; n = 200; very low-certainty evidence); fall down (RR 0.33, 95% CI 0.04 to 3.15; 1 RCT; n = 200; very low-certainty evidence); or choking (RR 0.2, 95% CI 0.01 to 4.11; 1 RCT; n = 200; very low-certainty evidence) when comparing structured risk assessment to standard professional care. There were no useable data for patient-related outcomes such as global state, acceptance of treatment, satisfaction with treatment, quality of life, service use, or costs. AUTHORS' CONCLUSIONS Based on the available evidence, it is not possible to conclude that structured aggression or violence risk assessment methods are effective for people with schizophrenia or schizophrenia-like illnesses. Future work should combine the use of interventions and structured risk assessment methods to prevent aggressive incidents in psychiatric inpatient settings.
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Affiliation(s)
- Maritta Välimäki
- School of Public Health, University of Helsinki, Helsinki, Finland
| | - Tella Lantta
- Department of Nursing Science, University of Turku, Turku, Finland
| | - Raija Kontio
- Department of Nursing Science, University of Turku, Turku, Finland
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de Boer T, Pietersma M, Tiemens B. Prediction of Disruptive Behavior over Time from Changes in Patients' Global Functioning in Acute Psychiatric Care. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2024:10.1007/s10488-024-01355-5. [PMID: 38521871 DOI: 10.1007/s10488-024-01355-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2024] [Indexed: 03/25/2024]
Abstract
Disruptive behavior of patients in acute psychiatric care is a problem for both patients and staff. Preventing a patient's impending disruption requires recognizing and understanding early signals. There are indications that a change in a patient's global functioning may be such a signal. The global functioning of patients is a multidimensional view on their functioning. It captures a patient's psychological symptoms, social skills, symptoms of violence, and activities in daily living. The aim of this study was to gain insight into the predictive value of global functioning on the risk of disruptive behavior of patients in acute psychiatric care. Also assessed was the time elapsed between the change in global functioning and a patient's disruptive behavior, which is necessary to know for purposes of early intervention. In a longitudinal retrospective study, we used daily measurements with the Brøset Violence Checklist (BVC) and the Kennedy Axis V (K-As) of each patient admitted to two acute psychiatric units over a period of six years. Data from 931 patients for the first 28 days after their admission were used for survival analysis and cox regression analysis. Disruptive behavior was mostly observed during the first days of hospitalization. Global functioning predicted disruptive behavior from the very first day of hospitalization. A cut-off score of 48 or lower on the K-As on the first admission day predicted a higher risk of disruptive behavior. If functioning remained poor or deteriorated substantially over three days, this was an additional signal of increased risk of disruptive behavior. Improvement in global functioning was associated with a decreased risk of disruptive behavior. More attention is needed for early interventions on global functioning to prevent disruptive behavior.
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Affiliation(s)
- Tamar de Boer
- Pro Persona Pompestichting, Nijmegen, The Netherlands
| | | | - Bea Tiemens
- Pro Persona Research, Wolfheze, The Netherlands.
- Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands.
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Saatchi B, Olshansky EF, Fortier MA. Irritability: A concept analysis. Int J Ment Health Nurs 2023; 32:1193-1210. [PMID: 36929104 DOI: 10.1111/inm.13140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 02/15/2023] [Accepted: 02/28/2023] [Indexed: 03/18/2023]
Abstract
Irritability is a term used to describe feelings of anger, annoyance and impatience, and is commonly experienced by individuals in daily life. However, there are diverse conceptualizations of irritability in public and clinical research, which often result in confusing irritability with anger and other overlapping concepts. This, in turn, leads to a lack of conceptual clarity. Accordingly, the purpose of this concept analysis was to explore the irritability concept, including its definitions, defining characteristics, antecedents, consequences and empirical referents. The findings showed that irritability is predominantly conceptualized as a psychophysiological concept in the literature. We demonstrated that irritability can be differentiated from overlapping concepts like anger by qualities, such as 'unpredictability and lowered emotion control', 'lowered threshold for negative emotional stimuli', 'being manifested in response to frustrative situations or physiological needs' and 'experience of disproportionate and unjustified emotional irritation'. Importantly, severe irritability prospectively predicts psychiatric disorders and greater impairments in health, financial, educational and social functioning in individuals. Taken together, our analysis showed that one should take into account the context, duration, intensity and importantly outcomes, when assessing irritability in an individual. Considering these findings and the presence of irritability in nursing practice, it is crucial for nurses to recognize and successfully identify this concept in the nursing care they provide within the diverse settings and patient populations.
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Affiliation(s)
- Babak Saatchi
- Sue & Bill Gross School of Nursing, University of California, Irvine, USA
| | - Ellen F Olshansky
- Sue & Bill Gross School of Nursing, University of California, Irvine, USA
| | - Michelle A Fortier
- Sue & Bill Gross School of Nursing, University of California, Irvine, USA
- Center on Stress & Health, University of California Irvine, Orange, California, USA
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Müller M, Brackmann N, Jäger M, Theodoridou A, Vetter S, Seifritz E, Hotzy F. Predicting coercion during the course of psychiatric hospitalizations. Eur Psychiatry 2023; 66:e22. [PMID: 36700423 PMCID: PMC9981454 DOI: 10.1192/j.eurpsy.2023.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Coercive measures (such as seclusion, mechanical restraint, and forced medication) during psychiatric inpatient treatment should be avoided whenever possible. Different interventions were already developed to reduce coercion, but for their effective application, it is crucial to know the risk factors of individuals and clinical situations that might be associated with coercion. Since the results of previous studies differ considerably the current study aims to fill this gap by evaluating the course of the exertion of coercion in detail. METHODS In this study, we analyzed clinical, procedural, and sociodemographic data from patients (n = 16,607 cases) who were treated as inpatients in Switzerland's largest psychiatric institution with 320 beds during the years 2017 to 2020. We used regression models to identify predictors for the exertion of coercion, the number of coercive measures during a treatment episode and time until exertion of the first and last coercive measure. RESULTS Coercive measures are mostly used during the first days of treatment. We identified clinical parameters such as manic or psychotic episodes to be the most relevant predictors for the exertion of coercion. Cases with those disorders also received coercion more often and earlier in their treatment course than other diagnostic groups. Other promoting factors for frequency and early application of coercion were involuntary admission and factors of chronicity and clinical severity. CONCLUSIONS Knowing the risk factors may help to target preventive strategies for those at highest risk. In particular, interventions should focus on the critical timeframe at the beginning of treatment.
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Affiliation(s)
- Mario Müller
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, University of Zurich, Zürich, Switzerland
| | - Nathalie Brackmann
- Department of Forensic Psychiatry, Psychiatric University Hospital Zurich, University of Zurich, Zürich, Switzerland
| | - Matthias Jäger
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, University of Zurich, Zürich, Switzerland
| | - Anastasia Theodoridou
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, University of Zurich, Zürich, Switzerland
| | - Stefan Vetter
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, University of Zurich, Zürich, Switzerland
| | - Erich Seifritz
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, University of Zurich, Zürich, Switzerland
| | - Florian Hotzy
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, University of Zurich, Zürich, Switzerland
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Okasha TA, Omar AN, Elserafy D, Serry S, Rabie ES. Violence in relation to cognitive deficits and symptom severity in a sample of Egyptian patients with schizophrenia. Int J Soc Psychiatry 2022; 69:689-699. [PMID: 36331135 DOI: 10.1177/00207640221132706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Patient with schizophrenia are significantly more likely to be violent than general population; and the consequences of this violence risk are often very serious for the patients, their caregivers, and the entire community. AIM To assess the risk of violence in patients with schizophrenia and its correlation with severity of symptoms and cognitive functions. METHODS A cross-sectional comparative study conducted in Okasha institute of psychiatry including 50 patients with schizophrenia compared to 50 healthy control group regarding violence risk as assessed by Historical, Clinical, and Risk Management-20 (HCR-20), case group was assessed using Structured Clinical Interview for DSM-IV (SCID-I), Positive and Negative Syndrome Scale (PANSS), cognitive functions were assessed by Wechsler Adult Intelligence Scale (WAIS), Trail Making Test (TMT) Part A and B, the Wisconsin Card Sorting Test (WCST), and the Wechsler Memory Scale (WMS). RESULTS There was a statistically significant difference between case and control groups regarding risk of violence where 58% of the case group were found to have risk of violence compared to only 18% in the control group. There was a significant correlation between this risk of violence and period of untreated psychosis, no of episodes, and history of substance use; also was significantly correlated with PANSS and Wisconsin card sorting test subscales. Regarding logistic regression analysis for factors affecting violence risk; total PANSS score and history of substance use were significant independent factors that increase violence risk. CONCLUSION Violence risk in patient with schizophrenia is a cardinal factor that may affect life of the patients, their family, and society; this risk can be affected by different factors including severity of symptoms, no of episodes, history of substance use, and cognitive function of the patients.
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Affiliation(s)
| | | | - Doha Elserafy
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Samar Serry
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Eman S Rabie
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Goulet MH, Lessard-Deschênes C. Le Modèle de prévention de l’utilisation des mesures de contrôle en santé mentale : une revue intégrative. SANTÉ MENTALE AU QUÉBEC 2022. [DOI: 10.7202/1094149ar] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Tölli S, Kontio R, Partanen P, Häggman-Laitila A. Conceptual framework for a comprehensive competence in managing challenging behaviour: The views of trained instructors. J Psychiatr Ment Health Nurs 2021; 28:692-705. [PMID: 33295055 DOI: 10.1111/jpm.12722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 10/10/2020] [Accepted: 11/30/2020] [Indexed: 11/27/2022]
Abstract
WHAT IS KNOWN ON THE SUBJECT?: There is body of knowledge available about the harms associated with restrictive interventions used in behaviour management, service users' perceptions of the use of restraints, and staff competence in behaviour management. The staff perspective has been studied in terms of staff exposure, responses to and prevention of aggression, staff-related factors associated with service user aggression, and staff attitudes and perceptions towards violence. The definitions of competence in behaviour management provided in training interventions are fragmented and based on unilateral measurements. Training interventions with the purpose of enhancing staff competence in behaviour management are organized regularly, yet there is a lack of clarity on how effective these interventions are. Inadequate conceptual understanding of behaviour management can weaken the effectiveness of these interventions. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Our study produced new knowledge by providing a preliminary conceptual framework that can be used to comprehensively describe and assess competence in managing challenging behaviour and to cover safely the whole care process. Humane care and ethical sensitivity should be the premises of interaction with people in distress. We also pointed out the needs for conceptual clarification of the concepts of confidence, support and restraint. We provide important new insight into the leadership and cultural issues of behaviour management that is relevant for patients, staff members and healthcare organizations. We found that staff members do not consider service user safety and workplace safety as opposing issues. Further, we provide new perspectives for prevention, the risk assessment process and effective communication in the context of behaviour management. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: A comprehensive understanding of the competences related to behaviour management will foster universal definitions for "support" and "restraint," which can then be used to ensure that the best practices are used for behaviour management. Organizational culture and participative leadership on behaviour management should be developed with a special focus on safety issues, common understanding of comprehensive competence, risk assessment and prevention, views regarding the use of restraints, and teamwork. ABSTRACT: Introduction Previous research concerning staff views of behaviour management has not considered instructors' views. The definitions of competence in behaviour management are fragmented, which can undermine the effectiveness of training interventions. Aim/Question This study aimed to describe Finnish and British Management of Actual or Potential Aggression instructors' perceptions of safety and behaviour management-related competences and create a conceptual framework for comprehensive competence. Method An explorative-descriptive qualitative approach with purposive sampling (N = 22), semi-structured interviews and abductive content analysis. Results Conceptual framework of comprehensive competence in managing challenging behaviour includes five categories-knowledge, skills, attitude, confidence and ethical sensitivity-and 21 subcategories. Competent staff and supportive leadership ensured safety, while inconsistent risk management culture, the health and behaviour of service users, and inadequate staff orientation endangered safety. Discussion The study produced new knowledge of safety issues and competences from the perspective of the instructors who deliver behaviour management training. Implications for practice Competence to manage challenging behaviour should be developed based on our conceptual framework to provide an effective and safe training. Prevention, the risk assessment process, alternative communication, and the definitions of "confidence," "support" and "restraint" should all be sufficiently addressed in future training.
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Affiliation(s)
- Sirpa Tölli
- University of Eastern Finland, Kuopio, Finland.,Oulu University of Applied Sciences, Oulu, Finland
| | - Raija Kontio
- Director Hyvinkää Hospital, Adjunct Professor Helsinki University, Helsinki, Finland
| | | | - Arja Häggman-Laitila
- University of Eastern Finland, Kuopio, Finland.,Social and Health Care, City of Helsinki, Helsinki, Finland
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8
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Campbell E, Jessee D, Whitney J, Vupputuri S, Carpenter J. Development and Implementation of an Emergent Documentation Aggression Rating Tool: Quality Improvement. J Emerg Nurs 2021; 47:696-706. [PMID: 34172291 DOI: 10.1016/j.jen.2021.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 04/22/2021] [Accepted: 04/26/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Workplace violence is prevalent in the emergency department, putting patients and staff at risk for harm. An ED-specific standardized tool is needed to promote a consistent assessment process to strengthen documentation of escalating patient behaviors, give justification for de-escalating interventions, and reduce restraints. The purpose of this project was to design, implement, and evaluate feasibility of an ED-specific tool to help nurses proactively identify and intervene with patients' escalating behaviors, capture better documentation of aggressive/violent patient events, and reduce restraint usage. METHODS A quality improvement design was used. The Emergent Documentation Aggression Rating Tool was constructed by combining evidence-based behavioral cues for potential aggression/violence with observed behaviors and successfully implemented interventions in patients. Nurses were trained on how to use the tool to rate patients' behaviors and take necessary action. Chart data were collected from August 2018 to December 2019 at a Midwestern Suburban Hospital Emergency Department. Chart audits and just-in-time education were conducted after implementation. Survey data were collected to evaluate nurses' perception of the tool's usefulness. RESULTS Use of the novel Emergent Documentation Aggression Rating Tool increased over time (67.36% in Quarter 3 2018 to 97.55% in Quarter 4 2019). After Emergent Documentation Aggression Rating Tool implementation, visual inspection of the time series indicated a decrease in percent restraints, and there was an overall increase in documented escalations de-escalations over time. The patients that escalated most frequently had diagnoses of alcohol use, suicidal ideations, pain-related complaints, or mental health issues. CONCLUSION The Emergent Documentation Aggression Rating Tool was feasible for emergency nurses to proactively identify and intervene with patients at risk for aggression/violence.
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Anderson KK, Jenson CE. Violence risk-assessment screening tools for acute care mental health settings: Literature review. Arch Psychiatr Nurs 2019; 33:112-119. [PMID: 30663614 DOI: 10.1016/j.apnu.2018.08.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 08/06/2018] [Accepted: 08/25/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Violence is a large concern for mental health professionals: 90% of physicians and nurses working in mental health areas have been subject to violence from patients. Approximately 80% of violent acts from patients are directed toward nurses. OBJECTIVE The purpose of this integrative literature review was to identify violence risk-assessment screening tools that could be used in acute care mental health settings. DESIGN The Stetler model of evidence-based practice guided the literature search, in which 8 violence risk-assessment tools were identified, 4 of which were used for further examination. RESULTS The Brøset Violence Checklist and Violence Risk Screening-10 provided the best assessment for violence in the acute care mental health setting. CONCLUSIONS Using a violence risk assessment screening tool helps identify patients at risk for violence allowing for quick intervention to prevent violent episodes.
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Affiliation(s)
- Kendra K Anderson
- Department of Nursing, Mayo Clinic, Rochester, MN, United States of America.
| | - Carole E Jenson
- Graduate Programs in Nursing, Winona State University-Rochester, Rochester, MN, United States of America
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10
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van den Berg SRN, Stringer B, van de Sande R, Draisma S. Care provider allocation on admissions to acute mental health wards: The development and validation of the Admission Team Score List. Int J Ment Health Nurs 2019; 28:86-95. [PMID: 29777566 DOI: 10.1111/inm.12476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/16/2018] [Indexed: 11/30/2022]
Abstract
Currently, support tools are lacking to prioritize steps in the care coordination process to enable safe practice and effective clinical pathways in the first phase of acute psychiatric admissions. This study describes the development, validity, and reliability of an acute care coordination support tool, the Admission Team Score List (ATSL). The ATSL assists in care provider allocation during admissions. Face validity and feasibility of the ATSL were tested in 77 acute admissions. Endscores of filled out ATSL's were translated to recommended team compositions. These ATSL team (ATSL-T) compositions were compared to the actually present team (AP-T) and the most preferred team (MP-T) composition in hindsight. Consistency between the ATSL-T and the MP-T was substantial; Kw = 0.70, P < 0.001, 95% CI [0.55-0.84]. The consistency between the ATSL-T and AP-T was moderate; Kw = 0.43, P < 0.001, 95% CI [0.23-0.62]. The ATSL has an adequate (inter-rater) reliability; ICC = 0.90, P < 0.001, 95% CI [0.65-0.91]. The ATSL study is an important step to promote safety and efficient care based on care provider allocation, for service users experiencing an acute admission. The ATSL may stimulate structured clinical decision-making during the hectic process around acute psychiatric admissions.
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Affiliation(s)
| | | | - Roland van de Sande
- Utrecht University of Applied Science & Parnassia Psychiatric Insitute, Utrecht, The Netherlands
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Jackson H, Baker J, Berzins K. What factors influence the decisions of mental health professionals to release service users from seclusion? Int J Ment Health Nurs 2018; 27:1618-1633. [PMID: 29934973 DOI: 10.1111/inm.12502] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/03/2018] [Indexed: 12/11/2022]
Abstract
Mental health policy stipulates seclusion should only be used as an intervention of last resort and for the minimum possible duration. Current evidence details which service users are more likely to be secluded, why they are secluded, and what influences the decision to seclude them. However, very little is known about the decision to release service users from seclusion. An integrative review was undertaken to explore the decision-making processes of mental health professionals which guide the ending of seclusion. The review used a systematic approach to gather and thematically analyse evidence within a framework approach. The twelve articles identified generated one overriding theme, maintaining safety. In addition, several subthemes emerged including the process of risk assessing which was dependent upon interaction and control, mediated by factors external to the service user such as the attitude and experience of staff and the acuity of the environment. Service users were expected to demonstrate compliance with the process ultimately ending in release and reflection. Little evidence exists regarding factors influencing mental health professionals in decisions to release service users from seclusion. There is no evidence-based risk assessment tool, and service users are not routinely involved in the decision to release them. Support from experienced professionals is vital to ensure timely release from seclusion. Greater insight into influences upon decisions to discontinue episodes may support initiatives aimed at reducing durations and use of seclusion.
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Affiliation(s)
- Haley Jackson
- School of Healthcare, University of Leeds, Leeds, UK
| | - John Baker
- School of Healthcare, University of Leeds, Leeds, UK
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12
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Wu Y, Kang R, Yan Y, Gao K, Li Z, Jiang J, Chi X, Xia L. Epidemiology of schizophrenia and risk factors of schizophrenia-associated aggression from 2011 to 2015. J Int Med Res 2018; 46:4039-4049. [PMID: 30088782 PMCID: PMC6166341 DOI: 10.1177/0300060518786634] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 06/12/2018] [Indexed: 12/15/2022] Open
Abstract
Objective To investigate the risk factors associated with aggression in patients with schizophrenia. Methods Patient clinical, behavioural, and demographic information was collected and reported online to the Beijing Mental Health Information Management System by psychiatrists. We used chi-square tests to analyse information between 2011 and 2015 to determine the prevalence and incidence of schizophrenia and the rate of aggression. We used univariate and binary logistic regression to analyse risk factors of aggressive behaviours. Results The prevalence and incidence of schizophrenia, and the proportion of cases displaying aggressive behaviour, increased considerably from 2011 to 2015. Risk of aggression was associated with non-adherence to medication (odds ratio [OR]: 2.92; 95% confidence intervals [CI]: 2.08-4.11), being unmarried (OR: 1.62; 95% CI: 1.03-2.55), having physical disease (OR: 3.26; 95% CI: 2.28-4.66), and higher positive symptom scores (OR: 2.01; 95% CI: 1.06-3.81). Physical disease was a risk factor associated with committing more than one type of aggression. Conclusion We confirmed that demographic factors, treatment-related factors, and clinical symptoms were associated with aggression in patients with schizophrenia in Beijing. A focus on improving controllable factors, including medication adherence and physical health status, might help to prevent aggressive behaviour.
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Affiliation(s)
- Yeqing Wu
- Department of Administration, Fengtai District Community Health
Center, Beijing, China
| | - Ruiying Kang
- Department of Administration, Fengtai District Community Health
Center, Beijing, China
| | - Yuxiang Yan
- Department of Epidemiology and Biostatics, School of Public
Health, Capital Medical University, Beijing, China
| | - Keming Gao
- Mood and Anxiety Clinic in the Mood Disorders Program,
Department of Psychiatry, Case Western Reserve University School of
Medicine/University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | - Zhiwu Li
- Fengtai Nanyuan Hospital, Beijing, China
| | - Jun Jiang
- Fengtai Nanyuan Hospital, Beijing, China
| | - Xueyang Chi
- Department of Administration, Fengtai District Community Health
Center, Beijing, China
| | - Lili Xia
- Department of Epidemiology and Biostatics, School of Public
Health, Capital Medical University, Beijing, China
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Loi F, Marlowe K. East London Modified-Broset as Decision-Making Tool to Predict Seclusion in Psychiatric Intensive Care Units. Front Psychiatry 2017; 8:194. [PMID: 29046647 PMCID: PMC5632740 DOI: 10.3389/fpsyt.2017.00194] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 09/19/2017] [Indexed: 11/16/2022] Open
Abstract
Seclusion is a last resort intervention for management of aggressive behavior in psychiatric settings. There is no current objective and practical decision-making instrument for seclusion use on psychiatric wards. Our aim was to test the predictive and discriminatory characteristics of the East London Modified-Broset (ELMB), to delineate its decision-making profile for seclusion of adult psychiatric patients, and second to benchmark it against the psychometric properties of the Broset Violence Checklist (BVC). ELMB, an 8-item modified version of the 6-item BVC, was retrospectively employed to evaluate the seclusion decision-making process on two Psychiatric Intensive Care Units (patients n = 201; incidents n = 2,187). Data analyses were carried out using multivariate regression and Receiver Operating Characteristic (ROC) curves. Predictors of seclusion were: physical violence toward staff/patients OR = 24.2; non-compliance with PRN (pro re nata) medications OR = 9.8; and damage to hospital property OR = 2.9. ROC analyses indicated that ELMB was significantly more accurate that BVC, with higher sensitivity, specificity, and positive likelihood ratio. Results were similar across gender. The ELMB is a sensitive and specific instrument that can be used to guide the decision-making process when implementing seclusion.
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Affiliation(s)
- Felice Loi
- Juniper Court Churchill Hospital CAS Behavioural Health, London, United Kingdom
| | - Karl Marlowe
- Millharbour PICU Mile End Hospital East London NHS Foundation Trust, London, United Kingdom
- Centre for Psychiatry Queen Mary University of London, London, United Kingdom
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14
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van de Sande R, Noorthoorn E, Nijman H, Wierdsma A, van de Staak C, Hellendoorn E, Mulder N. Associations between psychiatric symptoms and seclusion use: Clinical implications for care planning. Int J Ment Health Nurs 2017; 26:423-436. [PMID: 28960735 DOI: 10.1111/inm.12381] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/20/2017] [Indexed: 11/30/2022]
Abstract
Findings from an increasing number of studies suggest that incorporating systematic short-term risk assessments in treatment planning could lead to safer practice on psychiatric admissions wards. The aim of the present study was to investigate the associations between the scores of three structured observation tools - the Kennedy Axis V (K-Axis-V), the Brief Psychiatric Rating Scale (BPRS), and the Social Dysfunction and Aggression Scale (SDAS) - and seclusion. In total, 1840 weekly risk assessments with these observation scales were collected over 2342 admission weeks. These assessment scores related to 370 acutely-admitted psychiatric patients and were subjected to a multilevel analysis. It was found that several dynamic and static factors were related to seclusion. Dynamic factors included violent behaviour, current substance abuse, suspiciousness, and negativism. Static factors included ethnicity and having been diagnosed with a substance abuse disorder. The findings suggest that the incorporation of the Kennedy-Axis V, the BPRS, and the SDAS into standard practice might be helpful in identifying patients at high risk of seclusion, and could be supportive to treatment planning and clinical decision-making in the prevention of seclusion use in acute psychiatric settings.
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Affiliation(s)
- Roland van de Sande
- Department of Health, Utrecht University of Applied Science, Utrecht, The Netherlands
| | - Eric Noorthoorn
- GGnet Mental Health Centre, GGnet, Warnsveld, The Netherlands
| | - Henk Nijman
- Roosenburg, Altrecht Aventurijn, Den Dolder, The Netherlands
| | - Andre Wierdsma
- Department of Psychiatry, Research Centre O3, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Cees van de Staak
- Behavioural Science Institute, Radboud University Nijmegen, Nijmegen, The Netherlands
| | - Edwin Hellendoorn
- Acute Psychiatric Care, Parnassia Groep Bavo Europoort, Rotterdam, The Netherlands
| | - Niels Mulder
- Department of Psychiatry, Research Centre O3, ParnassiaBavoGroep, Erasmus Medical Centre, Rotterdam, The Netherlands
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15
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Fletcher J, Spittal M, Brophy L, Tibble H, Kinner S, Elsom S, Hamilton B. Outcomes of the Victorian Safewards trial in 13 wards: Impact on seclusion rates and fidelity measurement. Int J Ment Health Nurs 2017; 26:461-471. [PMID: 28960739 DOI: 10.1111/inm.12380] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/20/2017] [Indexed: 11/30/2022]
Abstract
Restrictive practices are used in response to conflict and aggression in psychiatric inpatient settings. Reducing such practices is the focus internationally of policy and legislative change, many initiatives, and a growing body of research. Safewards is a model and a set of 10 interventions designed to reduce conflict and containment in inpatient services. In the current study, we aimed to assess the impact of implementing Safewards on seclusion in Victorian inpatient mental health services in Australia. The study used a before-and-after design, with a comparison group matched for service type. Thirteen wards opted into a 12-week trial to implement Safewards and 1-year follow up. The comparison group was all other wards (n = 31) with seclusion facilities in the jurisdiction, matched to service type. Mandatorily-reported seclusion event data for all 44 wards over a 15-month period were analysed using negative binomial regression. Adherence to Safewards was measured via fidelity checklists at four time points: twice during the trial, post-trial, and at 1-year follow up. Seclusion rates were reduced by 36% in Safewards trial wards by the 12-month follow-up period (incidence rate ratios (IRR) = 0.64,) but in the comparison wards seclusion rates did not differ from baseline to post-trial (IRR = 1.17) or to follow-up period (IRR = 1.35). Fidelity analysis revealed a trajectory of increased use of Safewards interventions after the trial phase to follow up. The findings suggest that Safewards is appropriate for practice change in Victorian inpatient mental health services more broadly than adult acute wards, and is effective in reducing the use of seclusion.
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Affiliation(s)
- Justine Fletcher
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Mathew Spittal
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Lisa Brophy
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia.,Mind Australia, Monash University, Melbourne, Victoria, Australia
| | - Holly Tibble
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Stuart Kinner
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Monash University, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Griffith Criminology Institute and Menzies Health Institute Queensland, Griffith University, Brisbane, Queensland, Australia
| | - Steve Elsom
- School of Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Bridget Hamilton
- School of Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
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16
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Faay MDM, Valenkamp MW, Nijman H. Warning Signs prior to Aggressive Behavior in Child Psychiatric Units. Arch Psychiatr Nurs 2017; 31:43-47. [PMID: 28104057 DOI: 10.1016/j.apnu.2016.07.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 07/29/2016] [Accepted: 07/29/2016] [Indexed: 10/21/2022]
Abstract
This study aims at detecting and categorizing early warning signs of aggressive behavior in child psychiatric units. We analyzed 575 violent incident report forms and developed a coding scheme consisting of 16 warning signs. From the 575 incident report forms, a total of 1087 signs were coded. Most common warning signs were 'restlessness' (21.2%), 'not listening' (15.2%) and 'anger' (9.8%). These were also the most prevalent warning signs for the severe incidents. Although warning signs differ for each individual child, this study indicates that there are common warning signs for imminent aggressive incidents in child psychiatric facilities.
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Affiliation(s)
- Margo D M Faay
- Brain Center Rudolf Magnus, department of Psychiatry, University Medical Center Utrecht, The Netherlands.
| | - Marije W Valenkamp
- Erasmus Medical Center Sophia Children's Hospital, department of Child and Adolescent Psychiatry, Rotterdam, The Netherlands; VanMontfoort Consultancy, Woerden, The Netherlands
| | - Henk Nijman
- Behavioural Science Institute (BSI), Radboud University, Nijmegen, The Netherlands; Aventurijn - Fivoor, Den Dolder, The Netherlands
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17
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Välimäki M, Lantta T, Hätönen HM, Kontio R, Zhang S. Risk assessment for aggressive behaviour in schizophrenia. Hippokratia 2016. [DOI: 10.1002/14651858.cd012397] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Maritta Välimäki
- University of Turku; Department of Nursing Science; Turku Finland
- The Hong Kong Polytechnic University; Hong Kong China
| | - Tella Lantta
- University of Turku; Department of Nursing Science; Turku Finland
| | - Heli M Hätönen
- University of Turku; Department of Nursing Science; Turku Finland
| | - Raija Kontio
- University of Turku; Department of Nursing Science; Turku Finland
| | - Shuying Zhang
- Tongji University, School of Medicine; Nursing; 1239 Si Ping Road Shangai China 200092
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18
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Literature Synthesis: Patient Aggression Risk Assessment Tools in the Emergency Department. J Emerg Nurs 2016; 42:19-24. [DOI: 10.1016/j.jen.2015.01.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 01/07/2015] [Accepted: 01/28/2015] [Indexed: 11/21/2022]
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19
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Bullock R, McKenna B, Kelly T, Furness T, Tacey M. When reduction strategies are put in place and mental health consumers are still secluded: an analysis of clinical and sociodemographic characteristics. Int J Ment Health Nurs 2014; 23:506-12. [PMID: 25069674 DOI: 10.1111/inm.12078] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Internationally, seclusion practices continue to be the subject of intense clinical health service and academic scrutiny. Despite extensive efforts to reduce and eliminate this controversial practice, seclusion remains a clinical intervention widely used in contemporary mental health service settings. Early identification of people who are at risk for seclusion and the timely application of alternative evidence-based interventions are critical for reducing incidents of seclusion in real-world practice settings. This retrospective study aimed to determine the relationship between sociodemographic and clinical characteristics, and the use of seclusion for those mental health consumers for whom evidence-based seclusion-reduction initiatives had little impact. A 12-month centred moving average was fitted to seclusion data from a psychiatric inpatient unit over 2 years to determine stabilization in seclusion reduction. The number of consumers admitted was calculated from the point of stabilization for 1 year (n = 469). In this cohort, univariate analysis sought to compare the characteristics of those who were secluded and those who were not. A multivariate logistic regression model was undertaken to associate future seclusion based on significant independent variables. Of those people admitted, 88 (19%) were secluded. The majority of seclusions occurred in the first 5 days (70/88, 79%). Multivariate logistic regression indicated that three variables maintained their independent associative risk of seclusion: (i) age less than 35 years; (ii) assessment of risk of violence to others; and (iii) a history of seclusion. The implications of these findings for nursing practice are discussed.
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Affiliation(s)
- Rebecca Bullock
- Northern Area Mental Health Service, NorthWestern Mental Health, Melbourne Health, Melbourne, Victoria, Australia
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