Changes in the pattern of aggressive behaviour among inpatients with changed ward organization

Personality traits of nurses and organizational climate in relation to the use of coercion in psychiatric wards

PURPOSE

The aim of this study was to analyze the personality traits of nurses and the organizational climate in psychiatric wards affecting the frequency of the use of coercion.

DESIGN AND METHODS

The study applied a descriptive, longitudinal design based on a 1-year prospective observation.

FINDINGS

The best predictor for the initiation of coercion by nursing personnel was a low score on the Creative Personality Factor Scale in Adjective Check List and the low score in the area of Leadership in Kolb's Organizing Climate Questionnaire (KOQC). The best predictor for decisions to use coercion was the low score in the area Requirements in the KOQC, whereas the best predictors for the participation in coercion were a high value for Leadership area and a low value for Requirements area in KOQC.

PRACTICE IMPLICATIONS

The nursing personnel should be given frequent practical and theoretical training regarding the use of coercion.

The use of coercive interventions in mental health care in Germany and the Netherlands. A comparison of the developments in two neighboring countries

In this review, we compare the use of coercion in mental health care in Germany and in the Netherlands. Legal frameworks and published data on involuntary commitment, involuntary medication, seclusion, and restraint are highlighted as well as the role of guidelines, training, and attitudes held by psychiatrists and the public. Legal procedures regulating involuntary admission and commitment are rather similar, and so is the percentage of involuntary admissions and the rate per 100,000 inhabitants. However, opposing trends can be observed in the use of coercive interventions during treatment, which in both countries are considered as a last resort after all other alternative approaches have failed. In the Netherlands, for a long time seclusion has been considered as preferred intervention while the use of medication by force was widely disapproved as being unnecessarily invasive. However, after increasing evidence showed that number and duration of seclusions as well as the number of aggressive incidents per admission were considerably higher than in other European countries, attitudes changed within recent years. A national program with spending of 15 million € was launched to reduce the use of seclusion, while the use of medication was facilitated. A legislation is scheduled, which will allow also outpatient coercive treatment. In Germany, the latter was never legalized. While coercive treatment in Germany was rather common for involuntarily committed patients and mechanical restraint was preferred to seclusion in most hospital as a containment measure, the decisions of the Constitutional Court in 2011 had a high impact on legislation, attitudes, and clinical practice. Though since 2013 coercive medication is approvable again under strict conditions, it is now widely perceived as very invasive and last resort. There is evidence that this change of attitudes lead to a considerable increase of the use of seclusion and restraint for some patients.

Short-term prediction of threatening and violent behaviour in an Acute Psychiatric Intensive Care Unit based on patient and environment characteristics

BACKGROUND

The aims of the present study were to investigate clinically relevant patient and environment-related predictive factors for threats and violent incidents the first three days in a PICU population based on evaluations done at admittance.

METHODS

In 2000 and 2001 all 118 consecutive patients were assessed at admittance to a Psychiatric Intensive Care Unit (PICU). Patient-related conditions as actuarial data from present admission, global clinical evaluations by physician at admittance and clinical nurses first day, a single rating with an observer rated scale scoring behaviours that predict short-term violence in psychiatric inpatients (The Brøset Violence Checklist (BVC)) at admittance, and environment-related conditions as use of segregation or not were related to the outcome measure Staff Observation Aggression Scale-Revised (SOAS-R). A multiple logistic regression analysis with SOAS-R as outcome variable was performed.

RESULTS

The global clinical evaluations and the BVC were effective and more suitable than actuarial data in predicting short-term aggression. The use of segregation reduced the number of SOAS-R incidents.

CONCLUSIONS

In a naturalistic group of patients in a PICU segregation of patients lowers the number of aggressive and threatening incidents. Prediction should be based on clinical global judgment, and instruments designed to predict short-term aggression in psychiatric inpatients.

TRIAL REGISTRATIONS

NCT00184119/NCT00184132.

Overcrowding in psychiatric wards and physical assaults on staff: data-linked longitudinal study

BACKGROUND

Patient overcrowding and violent assaults by patients are two major problems in psychiatric healthcare. However, evidence of an association between overcrowding and aggressive behaviour among patients is mixed and limited to small-scale studies.

AIMS

This study examined the association between ward overcrowding and violent physical assaults in acute-care psychiatric in-patient hospital wards.

METHOD

Longitudinal study using ward-level monthly records of bed occupancy and staff reports of the timing of violent acts during a 5-month period in 90 in-patient wards in 13 acute psychiatric hospitals in Finland. In total 1098 employees (physicians, ward head nurses, registered nurses, licensed practical nurses) participated in the study. The outcome measure was staff reports of the timing of physical assaults on both themselves and ward property.

RESULTS

We found that 46% of hospital staff were working in overcrowded wards, as indicated by >10 percentage units of excess bed occupancy, whereas only 30% of hospital personnel were working in a ward with no excess occupancy. An excess bed occupancy rate of >10 percentage units at the time of an event was associated with violent assaults towards employees (odds ratio (OR) = 1.72, 95% CI 1.05-2.80; OR = 3.04, 95% CI 1.51-6.13 in adult wards) after adjustment for confounding factors. No association was found with assaults on ward property (OR = 1.06, 95% CI 0.75-1.50).

CONCLUSIONS

These findings suggest that patient overcrowding is highly prevalent in psychiatric hospitals and, importantly, may increase the risk of violence directed at staff.

A cross-sectional prospective study of seclusion, restraint and involuntary medication in acute psychiatric wards: patient, staff and ward characteristics

Background

Previous research on mental health care has shown considerable differences in use of seclusion, restraint and involuntary medication among different wards and geographical areas. This study investigates to what extent use of seclusion, restraint and involuntary medication for involuntary admitted patients in Norwegian acute psychiatric wards is associated with patient, staff and ward characteristics. The study includes data from 32 acute psychiatric wards.

Methods

Multilevel logistic regression using Stata was applied with data from 1016 involuntary admitted patients that were linked to data about wards. The sample comprised two hierarchical levels (patients and wards) and the dependent variables had two values (0 = no use and 1 = use). Coercive measures were defined as use of seclusion, restraint and involuntary depot medication during hospitalization.

Results

The total number of involuntary admitted patients was 1214 (35% of total sample). The percentage of patients who were exposed to coercive measures ranged from 0-88% across wards. Of the involuntary admitted patients, 424 (35%) had been secluded, 117 (10%) had been restrained and 113 (9%) had received involuntary depot medication at discharge. Data from 1016 patients could be linked in the multilevel analysis. There was a substantial between-ward variance in the use of coercive measures; however, this was influenced to some extent by compositional differences across wards, especially for the use of restraint.

Conclusions

The substantial between-ward variance, even when adjusting for patients' individual psychopathology, indicates that ward factors influence the use of seclusion, restraint and involuntary medication and that some wards have the potential for quality improvement. Hence, interventions to reduce the use of seclusion, restraint and involuntary medication should take into account organizational and environmental factors.

Violent behavior in acute psychiatric inpatient facilities: a national survey in Italy

Violence committed by acute psychiatric inpatients represents an important and challenging problem in clinical practice. Sociodemographic, clinical, and treatment information were collected for 1324 patients (677 men and 647 women) admitted to Italian public and private acute psychiatric inpatient facilities during an index period in 2004, and the sample divided into 3 groups: nonhostile patients (no episodes of violent behavior during hospitalization), hostile patients (verbal aggression or violent acts against objects), and violent patients (authors of physical assault). Ten percent (N = 129) of patients showed hostile behavior during hospitalization and 3% (N = 37) physically assaulted other patients or staff members. Variables associated with violent behavior were: male gender, <24 years of age, unmarried status, receiving a disability pension, having a secondary school degree, compulsory admission, hostile attitude at admission, and a diagnosis of schizophrenia, bipolar disorder, personality disorder, mental retardation, organic brain disorder or substance/alcohol abuse. Violent behavior during hospitalization was a predictive factor for higher Brief Psychiatric Rating Scale scores and for lower Personal and Social Performance scale scores at discharge. Despite the low percentage of violent and hostile behavior observed in Italian acute inpatient units, this study shed light on a need for the careful assessment of clinical and treatment variables, and greater effort aimed at improving specific prevention and treatment programs of violent behavior.

Changes in the occurrences of coercive interventions and staff injuries on a psychiatric intensive care unit

The purpose of this study was to compare the occurrences of coercive interventions and violence-related staff injuries before and after a 2-year violence prevention intervention on a psychiatric intensive care unit. The intervention aimed to improve nursing care by addressing patient violence from multiple perspectives. During the study, the unit was reorganized toward a higher concentration of severely disturbed patients. The results showed an increased proportion of coercive interventions without a corresponding increase in staff injuries. Use of coercive interventions is discussed in relation to a safe environment for both patients and staff.

Violence in psychiatric units: a 7-year Italian study of persistently assaultive patients

BACKGROUND

The problem of violence and aggressive behaviour among patients with psychiatric disorders need careful assessment to improve the quality of psychiatric care. The aim of this paper is to describe the characteristics of repeated episodes of violence among patients admitted to an Italian psychiatric ward.

METHODS

All violent behaviours, which occurred in a 15-bed psychiatric inpatient unit over a 7-year period, were assessed by using the Staff Observation Aggression scale (SOAS).

RESULTS

Of a total of 3.507 admissions, 409 aggressive episodes were recorded by 160 patients (rate per admission 11.6%). A total of 65 patients exhibited two or more episodes and 95 patients showed a single episode. Repeatedly violent patients had a higher length of stay in the unit, a higher number of previous admissions and a higher number of previous violent episodes. No difference was found in terms of psychiatric diagnosis, socio-demographic variables, type of admission (voluntary versus involuntary), ward overcrowding and characteristics of violent episodes (means, aims and consequence).

CONCLUSIONS

In spite of the low prevalence of violent incidents among Italian psychiatric inpatients, careful monitoring of clinical variables associated with repeated violent episodes may help physicians recognise and prevent violence episodes among acute psychiatric inpatients.

Evaluation of the Perception of Aggression Scale (POAS) in Swedish nurses

Even though much is known about individual risk factors for institutional violence, large variations in frequency between institutions still remain unexplained. Staff attitudes have been pointed out as a possible important and explaining factor. The Perception of Aggression Scale (POAS) is a newly developed attitude inventory assessing nurses' attitudes toward aggressive patients. The aims of this study are to evaluate the factor structure of the Swedish version of the POAS and to evaluate its discriminatory capacity in different groups of nurses. The shortened POAS was handed out to 357 nurses at 12 different psychiatric wards in Sweden. Responses were analysed with exploratory principal component factor analysis. The emerging factors were correlated in a rank-transformed multiple regression analysis to individual characteristics of each nurse. The factor analyses revealed exactly the same factor structure in this Swedish sample of nurses as in previous German and Dutch studies. When expanding the factor analysis, a three-factor solution emerged. It was also found that the factor "Aggression as a protective measure" was correlated to age and experience of aggression management training while the factor "Aggression as dysfunctional/undesirable phenomenon" was sensitive for gender. The shortened 12-item POAS contains three discrete dimensions and thus seems to be a solid tool for evaluating attitudes towards violence. Of special interest is the possibility that the factor "Aggression as a protective measure" could be sensitive to training. Further studies should correlate dimensions of staff attitudes to the occurrence of inpatient violence.

Evaluating the validity of anger regulation problems, interpersonal style, and disturbed mental state for predicting inpatient violence

Research has been conducted to try to identify risk factors to help predict which patients will be violent during psychiatric hospitalization. Despite the relatively large amount of research conducted, it is difficult to draw any firm conclusions, as the studies vary considerably in study design, methods used, and choice of outcome measures. Studies also tend to focus on risk prediction, even though risk management is the primary aim of clinical practice in mental health services and few studies have focused on a theoretical basis for understanding violence. This study assessed the predictive validity of brief assessment scales in a sample of 94 forensic inpatients who had been inpatient for a median of 521 days, to test the hypotheses that anger regulation problems, interpersonal style, and disturbed mental state would be linked to increased violence risk in a forensic hospital during a hospital stay. The outcome variables for this study were physical violence against another and/or clear threats of physical violence. The results of this study provide support for the hypotheses, and this remained the case after controlling for age, gender, length of stay, and presence of major mental disorder. The findings should not only assist clinicians with assessment and management of risk but also support the reconceptualizing of risk prediction research to reflect the task of clinical risk management.

Prediction of inpatient violence

OBJECTIVE

An overview of studies on predictors and on the accuracy of prediction of inpatient violence should be given.

METHOD

To date, the published data do not allow a systematic meta-analysis due to different sample characteristics, different measures and definitions of violence, and different time frames of observation. Published studies were reviewed regarding significant predictors of inpatient violence.

RESULTS

Predictors of violence in institutional settings are different from predictors of violence in the community: variables such as sex, age, diagnosis and alcohol abuse play a minor role, while clinical and psychopathological variables are prominent. Only history of violence is a robust static predictor. The total level of positive and general psychotic symptoms seems to enhance the violence risk of inpatients, whereas results concerning specific features like delusions or command hallucinations are contradictory due to inevitable problems of sample selection. The accuracy of clinical predictions is better than chance but limited by the effects of therapeutic interventions and research artefacts.

CONCLUSION

The author argues that more precise determinations of the violence risk in institutions will fail and that the role of environmental factors has often been underestimated.

Fifteen years of research with the Staff Observation Aggression Scale: a review

OBJECTIVE

Research on the prevalence and causes of in-patient aggression has been hindered by the use of different methods for measuring aggression. Since Palmstierna and Wistedt presented the Staff Observation Aggression Scale (SOAS) in 1987, this data collection method has been used in various studies, which may make comparisons more useful.

METHOD

Studies with SOAS aggression data were compiled using MEDLINE, the Internet, and references from SOAS papers.

RESULTS

Reviews of studies on psychometric properties suggest fair to good inter-rater reliability and validity for SOAS assessments. The number of aggressive incidents per patient per year found on acute admissions wards (n = 38) considerably varied, with a range of 0.4-33.2 incidents (mean = 9.3).

CONCLUSION

Although the aggression data included in the present review were obtained in highly comparable ways, substantial differences in aggression rates between wards were still found. Some countries (e.g. the Netherlands) appear to have a relatively high incidence of aggression on acute wards.

Violence and its prediction at a psychiatric hospital

Aggressive behaviour in psychiatric inpatients was assessed before and after a training course for staff members. The Social Dysfunction Aggression Scale (SDAS) was used to report and assess aggressive behaviour over time, and the Staff Observation Aggression Scale (SOAS) to report and assess single aggressive incidents. In addition, the numbers of nursing staff members who were on sick leave because of injuries in the periods before and after the course were recorded and compared. No statistically significant reduction was found in the number of aggressive patients or in the number of staff members on sick leave. One interesting finding was a lower reporting on the SOAS of perceived aggressive incidents after the training course in comparison with the SDAS reports. Directed verbal aggressiveness and violence towards things were found to be predictors of violence.

Day-night variation in aggressive behavior among psychiatric inpatients

Self-directed aggressive behaviors of human beings show a 24h pattern. The aim of this study was to evaluate if violence of psychiatric inpatients against one another and hospital staff varies over the 24h. The clock time occurrence of 334 episodes of assault behaviors by 119 psychiatric inpatients (78 males and 41 females, mean age 34.8+/-11.3 years) committed during a 5-year span in the psychiatric unit of the university-based hospital of Ferrara, Italy, was evaluated. The clock time of each event was categorized by hour during the 24h and into one of four 6h intervals for analysis of temporal variation by cosinor and chi2 tests, respectively. A significant 24h variation, characterized by an early afternoon peak, was detected irrespective of gender and number (single vs. repeated) of episodes committed. Changes during the 24h in ward activity, patient contact, and endogenous circadian rhythms are likely to contribute to the observed 24h pattern, although further study is needed to confirm our findings and to define causal factors.

Crowding and violent behavior: the influence of patient density on violent and self-harming behaviour at a medium secure unit

This study examines the influence of patient density (crowding) and number of potential perpetrators on the number of incidents of violence and self-harm at a medium secure unit. Of 2,053 incidents examined over a period of 974 days, 73% were perpetrated by 20% of the patients, the majority by patients identified as potential perpetrators. Increased patient density was not associated with increased risk of violence or self-harm. There was no evidence to suggest that the presence of those identified as potentially violent or self-harming increased the risk of others engaging in such behaviour.