Registered nurses' and behavior health associates' responses to violent inpatient interactions on behavioral health units

'Alright my lovely': The use of terms of endearment as a mitigation device in the care of people living with dementia in the acute hospital environment

This paper examines how terms of endearment (ToE) are used as a mitigation device in interactions between staff and people living with dementia (PLWD) in the acute hospital environment. ToE are often discouraged in training for healthcare staff. However, this research demonstrates that they are still commonly used in practice. Using conversation analysis, video and audio data were examined to identify the interactional functions of ToE. Analysis showed that ToE play an important role in mitigating potentially face-threatening actions such as when patients are asked to repeat hard-to-interpret talk, or when patient agency is compromised through instruction sequences or having necessary healthcare tasks undertaken. The success of this mitigation is sensitive to the specific interactional circumstances, as well as the responsiveness of the HCP to the patient's voiced concerns. These findings have implications for healthcare practice, training and wider care of PLWD.

A systematic review and thematic synthesis of inpatient nursing staff experiences of working with high-risk patient behaviours

INTRODUCTION

Nursing staff are frequently exposed to high-risk patient behaviours within inpatient health services, yet staff commonly report a lack of training and support in managing these behaviours.

AIM

The aim of the study was to examine nursing staff experiences of high-risk behaviours in inpatient mental health settings.

METHODS

Four electronic databases (CINAHL, Medline, PsycINFO, EMBASE) were searched. The protocol for this review was prospectively registered in PROSPERO (Ref: CRD42022334739). A meta-synthesis of nursing staff's experiences of high-risk behaviours in inpatient mental health settings was conducted.

RESULTS

We identified 30 eligible studies. Six themes were constructed from the meta-synthesis: the social contract of care; the function of risk behaviours; the expectation of risk; risk as a relational concept; navigating contradictions in care; the aftermath.

DISCUSSION

Nursing staff conceptualize risk as a meaningful behaviour shaped by patient, staff and environmental factors. Managing risk is an ethical dilemma for nursing staff and they require more training and support in ethical risk decision-making.

IMPLICATIONS FOR PRACTICE

Inpatient mental healthcare services should formulate and manage risk as a relational concept comprising staff, patient and environmental factors. Future research and clinical practice should place further consideration on the varied experiences of different types of risk behaviours.

RELEVANCE STATEMENT

Nursing staff are frequently exposed to high-risk patient behaviours within inpatient health services, yet staff commonly report a lack of training and support in managing these behaviours. This systematic review offers insights into how high-risk behaviours are experienced by nursing staff and makes recommendations about how to improve the understanding and management of them. Inpatient mental healthcare services should formulate and manage risk as a relational concept comprising staff, patient and environmental factors. Future research and clinical practice should place further consideration on the varied experiences of different types of risk behaviours.

Caring Knowledge as a Strategy to Mitigate Violence against Nurses: A Discussion Paper

Violence against nurses is a disturbing trend in healthcare that has reached epidemic proportions globally. These violent incidents can result in physical and psychological injury, exacerbating already elevated levels of stress and burnout among nurses, further contributing to absenteeism, turnover, and intent to leave the profession. To ensure the physical and mental well-being of nurses and patients, attention to the development of strategies to reduce violence against nurses must be a priority. Caring knowledge-rooted in the philosophy of care-is a potential strategy for mitigating violence against nurses in healthcare settings. We present what caring knowledge is, analyze its barriers to implementation at the health system and education levels and explore potential solutions to navigate those barriers. We conclude how the application of models of caring knowledge to the nurse-patient relationship has the potential to generate improved patient safety and increased satisfaction for both nurses and patients.

Effects of a nonviolent communication-based anger management program on psychiatric inpatients

This quasi-experimental study aimed to determine the effects of a nonviolent communication-based anger management program on self-esteem, anger expression, and aggression in 44 psychiatric inpatients (experimental group: n = 21; control group: n = 24). The program consisted of six sessions of 60 min each, using a non-equivalent control group pretest-posttest design, and thereafter analyzing the intervention effects. Results showed statistically significant differences between the experimental and control groups in anger expression and anger suppression. There were positive, though not statistically significant, changes in self-esteem and aggression. The findings indicated a decreasing effect of anger expression and anger suppression.

Experience of violence, coping and support for nurses working in acute psychiatric wards

Background

Acute psychiatric wards are stressful working environments because of the nature of the mental illness of patients admitted. These patients present with a variety of complex psychiatric problems and social control that require skilled and competent nurses to manage them. The shortage of nurses, especially with advanced psychiatric qualifications or necessary experience, may create challenges for nurses as they navigate this stressful working environment.

Aim

The aim of this study was to explore and describe nurses’ experience of patient violence, coping strategies and received support whilst working in acute wards in psychiatric hospitals.

Setting

This study was conducted in six acute wards of the three psychiatric hospitals in Cape Town, South Africa.

Methods

A qualitative, explorative, descriptive design was conducted using semi-structured interviews to obtain data from 14 nurses working in acute wards in three psychiatric hospitals in the Western Cape.

Results

Five themes were generated using thematic analysis: violence perceived to be ‘part of the job’, contributing factors to patient violence, physical and psychological effects on nurses, adaptive and maladaptive coping strategies and perceived support from stakeholders.

Conclusion

Participants normalised patient violent behaviour as being part of the job to minimise the physical and psychological effects of the traumatic experience. Adaptive and maladaptive coping strategies were used to cope with the traumatic experiences of being assaulted by patients. Recommendations allude to practising self-care and attendance of training in the management of aggressive patients for nurses, to enhance a variety of adaptive coping strategies.

Patient safety in inpatient mental health settings: a systematic review

OBJECTIVES

Patients in inpatient mental health settings face similar risks (eg, medication errors) to those in other areas of healthcare. In addition, some unsafe behaviours associated with serious mental health problems (eg, self-harm), and the measures taken to address these (eg, restraint), may result in further risks to patient safety. The objective of this review is to identify and synthesise the literature on patient safety within inpatient mental health settings using robust systematic methodology.

DESIGN

Systematic review and meta-synthesis. Embase, Cumulative Index to Nursing and Allied Health Literature, Health Management Information Consortium, MEDLINE, PsycINFO and Web of Science were systematically searched from 1999 to 2019. Search terms were related to 'mental health', 'patient safety', 'inpatient setting' and 'research'. Study quality was assessed using the Hawker checklist. Data were extracted and grouped based on study focus and outcome. Safety incidents were meta-analysed where possible using a random-effects model.

RESULTS

Of the 57 637 article titles and abstracts, 364 met inclusion criteria. Included publications came from 31 countries and included data from over 150 000 participants. Study quality varied and statistical heterogeneity was high. Ten research categories were identified: interpersonal violence, coercive interventions, safety culture, harm to self, safety of the physical environment, medication safety, unauthorised leave, clinical decision making, falls and infection prevention and control.

CONCLUSIONS

Patient safety in inpatient mental health settings is under-researched in comparison to other non-mental health inpatient settings. Findings demonstrate that inpatient mental health settings pose unique challenges for patient safety, which require investment in research, policy development, and translation into clinical practice.

PROSPERO REGISTRATION NUMBER

CRD42016034057.

Violence Management in a Nigerian Psychiatric Facility: Psychiatric-Mental Health Nurses' Current Practices and Their Effectiveness

Patient violence in mental health care settings is daunting and stressful, as well as increasingly burdensome for professionals in low/middle income countries, specifically Africa. Patient violence has contributed to increased work hazards for health care professionals and may lead to patients being sedated or restrained, potentially resulting in injury to either the patient or provider. The current study assessed Nigerian psychiatric-mental health nurses' current practices of violence management in a hospital in Southwest Nigeria. A qualitative approach, specifically focus group discussion, was used. Results of the study show that patients and providers are prone to maltreatment. Professionals desire involvement of armed military officials to combat acts of violence by psychiatric patients who take advantage of nurses' gender, inexperience, or being lonely on duty, as well as the time of day, to attack nurses. Professionals have reportedly died in the process of violence management. Intervention studies on violence management in African mental health care settings are a priority for future research. [Journal of Psychosocial Nursing and Mental Health Services, 56(11), 37-45.].

The Spirit and Intent of Motivational Interviewing

PURPOSE

To describe an educational program to improve inpatient psychiatric nursing staff communication skills to better provide patient-centered care throughout patient hospitalization.

DESIGN AND METHODS

Delivered and evaluated an educational program to increase inpatient staff knowledge and use of communication skills during patient encounters.

CONCLUSIONS

Emphasizing the spirit and intent of motivational interviewing in a training program results in a translation of the newly obtained knowledge into nursing practice, as evidenced by observed use of motivational interviewing skills during which patient encounters to strengthen the therapeutic alliance.

PRACTICE IMPLICATIONS

Advanced Psychiatric Nurse Practitioners can provide an important role of coaching/mentorship for inpatient psychiatric nursing staff to further develop communication skills that are meaningful, patient-centered, and may lead to improved treatment adherence.

Safety in psychiatric inpatient care: The impact of risk management culture on mental health nursing practice

The discourse of safety has informed the care of individuals with mental illness through institutionalization and into modern psychiatric nursing practices. Confinement arose from safety: out of both societal stigma and fear for public safety, as well as benevolently paternalistic aims to protect individuals from self‐harm. In this paper, we argue that within current psychiatric inpatient environments, safety is maintained as the predominant value, and risk management is the cornerstone of nursing care. Practices that accord with this value are legitimized and perpetuated through the safety discourse, despite evidence refuting their efficacy, and patient perspectives demonstrating harm. To illustrate this growing concern in mental health nursing care, we provide four exemplars of risk management strategies utilized in psychiatric inpatient settings: close observations, seclusion, door locking and defensive nursing practice. The use of these strategies demonstrates the necessity to shift perspectives on safety and risk in nursing care. We suggest that to re‐centre meaningful support and treatment of clients, nurses should provide individualized, flexible care that incorporates safety measures while also fundamentally re‐evaluating the risk management culture that gives rise to and legitimizes harmful practices.

Aggression in psychiatric hospitalizations: a qualitative study of patient and provider perspectives

BACKGROUND

When the people hospitalized in psychiatric units demonstrate aggression, it harms individuals and creates legal and financial issues for hospitals. Aggression has been linked to inpatient, clinician and environmental characteristics. However, previous work primarily accessed clinicians' perspectives or administrative data and rarely incorporated inpatients' insights. This limits validity of findings and impedes comparisons of inpatient and clinician perspectives.

AIMS

This study explored and compared inpatient and clinician perspectives on the factors affecting verbal and physical aggression by psychiatric inpatients.

METHODS

This study used an interpretive theoretical framework. Fourteen inpatients and 10 clinicians were purposefully sampled and completed semi-structured interviews. Data were analyzed using inductive thematic analysis.

RESULTS

Six themes were identified at personal and organizational levels. The three person-level themes were major life stressors, experience of illness and interpersonal connections with clinicians. The three organization-level themes were physical confinement, behavioural restrictions and disengagement from treatment decisions.

CONCLUSIONS

Aggression is perceived to have a wide range of origins spanning personal experiences and organizational policies, suggesting that a wide range of prevention strategies are needed.

Violent events, ward climate and ideas for violence prevention among nurses in psychiatric wards: a focus group study

BACKGROUND

Patient violence against nurses in their work environments is a widespread global concern, particularly in the field of mental health care. A high prevalence of violent events impacts the well-being of nurses and may also impair overall ward climate. However, it has been proposed that nurses' use limited techniques to prevent patient violence, and, therefore, more comprehensive methods for dealing with patient violence are needed. There is still restricted understanding of the ward climate during the occurrence of a violent event as well as how these incidents could be more effectively prevented. This study aimed to explore nurses' experiences of violent events in psychiatric wards, give insight into ward climates and examine suggestions for violence prevention.

METHODS

This study employed a descriptive, exploratory design including focus groups (n = 5) and open-ended questions. The participants were registered and enrolled nurses (n = 22) working on three closed psychiatric in-patient wards in one Finnish hospital district. Focus groups were tape-recorded, transcribed and analyzed with inductive content analysis.

RESULTS

Nurses' experiences of violent events included a variety of warning signs and high-risk situations which helped them to predict forthcoming violence. Patient-instigated violent events were described as complicated situations involving both nurses and patients. When the wards were overloaded with work or emotions, or if nurses had become cynical from dealing with such events, well-being of nurses was impaired and nursing care was complicated. Suggestions for violence prevention were identified, and included, for example, more skilled interaction between nurses and patients and an increase in contact between nurses and patients on the ward.

CONCLUSIONS

This study revealed the complexity of violent events on psychiatric wards as well as the implications of these events on clinical practice development and training, administration and policy. A routine process is needed through which nurses' experiences and ideas concerning prevention of violent events are acknowledged.

Registered nurses' experiences of patient violence on acute care psychiatric inpatient units: an interpretive descriptive study

BACKGROUND

Nurses working in acute care psychiatry settings experience high rates of patient violence which influences outcomes for nurses and the organization. This qualitative study explored psychiatric nurses' experiences of patient violence in acute care inpatient psychiatric settings.

METHODS

An interpretive descriptive design guided this study that included 17 semi-structured interviews with a purposeful sample of 12 Canadian registered nurses who self-reported experiencing patient violence within acute care inpatient psychiatry. Thematic analysis and constant comparison techniques were used for analysis. A problem, needs and practice analysis was also used to structure overall data interpretation.

RESULTS

Thirty three unique exposures to patient violence among the sample of nurses were analysed. Nurses reported experiencing physical, emotional and verbal violence. For many, patient violence was considered "part of the job." Nurses often struggled with role conflict between one's duty to care and one's duty to self when providing care following a critical incident involving violence. Issues of power, control and stigma also influenced nurse participant perceptions and their responses to patient violence. Nurses used a variety of strategies to maintain their personal safety and to prevent, and manage patient violence. Nurses endorsed the need for improved education, debriefing following an incident, and a supportive work environment to further prevent patient violence. Present findings have implications for reducing the barriers to reporting violent experiences and the creation of best practice guidelines to reduce patient violence in the workplace.

CONCLUSIONS

Understanding the perspectives and experiences of nurses in acute inpatient psychiatry leads to greater understanding of the phenomenon of patient violence and may inform the development of interventions to prevent and to respond to patient violence, as well as support nurses working within the acute care setting.

Registered nurses' experiences of patient violence on acute care psychiatric inpatient units: an interpretive descriptive study

Background

Nurses working in acute care psychiatry settings experience high rates of patient violence which influences outcomes for nurses and the organization. This qualitative study explored psychiatric nurses’ experiences of patient violence in acute care inpatient psychiatric settings.

Methods

An interpretive descriptive design guided this study that included 17 semi-structured interviews with a purposeful sample of 12 Canadian registered nurses who self-reported experiencing patient violence within acute care inpatient psychiatry. Thematic analysis and constant comparison techniques were used for analysis. A problem, needs and practice analysis was also used to structure overall data interpretation.

Results

Thirty three unique exposures to patient violence among the sample of nurses were analysed. Nurses reported experiencing physical, emotional and verbal violence. For many, patient violence was considered “part of the job.” Nurses often struggled with role conflict between one’s duty to care and one’s duty to self when providing care following a critical incident involving violence. Issues of power, control and stigma also influenced nurse participant perceptions and their responses to patient violence. Nurses used a variety of strategies to maintain their personal safety and to prevent, and manage patient violence. Nurses endorsed the need for improved education, debriefing following an incident, and a supportive work environment to further prevent patient violence. Present findings have implications for reducing the barriers to reporting violent experiences and the creation of best practice guidelines to reduce patient violence in the workplace.

Conclusions

Understanding the perspectives and experiences of nurses in acute inpatient psychiatry leads to greater understanding of the phenomenon of patient violence and may inform the development of interventions to prevent and to respond to patient violence, as well as support nurses working within the acute care setting.

Engagement as an Element of Safe Inpatient Psychiatric Environments

BACKGROUND

The American Psychiatric Nurses Association (APNA) Institute for Safe Environments (ISE) has focused on key elements that affect safety in psychiatric treatment environments; one of these key elements is patient engagement. An ISE workgroup discussed and reviewed the literature on engagement and safety in inpatient psychiatric settings. This article presents what we have learned about the role that engagement plays in inpatient treatment of severely mentally ill individuals and evidence that links nurse-patient engagement to safety.

OBJECTIVES

To describe, using supporting literature, the role that nurse-patient engagement plays in creating safe, therapeutic environments for individuals with severe mental illness.

DESIGN

(1) Define engagement and describe why it is an important element of safe treatment environments; (2) identify what helps and what hinders patients in their engagement with nurses, and nurses in their engagement with patients; (3) describe how engagement may improve unit safety; and (4) propose recommendations and set future directions for practice, research, and education.

CONCLUSION

Engagement may provide the foundation for safe, therapeutic, and recovery-oriented treatment. In the future, APNA's ISE plans to build upon this foundation by developing a clinical model of nurse-patient engagement and safety by drawing together emerging research and practice models.

Nothing changes, nobody cares: understanding the experience of emergency nurses physically or verbally assaulted while providing care

INTRODUCTION

Workplace violence has been recognized as a violent crime that requires targeted responses from employers, law enforcement, and the community. According to data from the Bureau of Labor Statistics, the most common source of nonfatal injuries and illnesses requiring days away from work in the health care and social assistance industry was assault on the health care worker. What is not well understood are the precursors and sequelae of violence perpetrated against emergency nurses and other health care workers by patients and visitors. The purpose of this study was to better understand the experience of emergency nurses who have been physically or verbally assaulted while providing patient care in US emergency departments.

METHODS

The study was conducted using a qualitative descriptive exploratory design. The sample consisted of 46 written narratives submitted by e-mail by emergency nurses describing the experience of violence while providing care at work. Narrative analysis and constant comparison were used to identify emerging themes in the narratives.

RESULTS

"Environmental," "personal," and "cue recognition" were identified as the themes. Overall, nurses believed that violence was endemic to their workplace and that both limited recognition of cues indicating a high-risk person or environment and a culture of acceptance of violence were barriers to mitigation.

DISCUSSION

These findings are consistent with the extant literature but with an added contribution of clearly identifying an underlying cultural acceptance of violence in the emergency department, as well as a distinct lack of cue recognition, in this sample of emergency nurses.

Nurses’ experiences and understanding of workplace violence in a trauma and emergency department in South Africa

Violence in South African society has reached epidemic levels and has permeated the walls of the workplace. The aim of the study was to gain a deeper understanding of how nurses experience and understand workplace violence perpetrated by patients, and to make recommendations to reduce this type of violence. A qualitative, exploratory and descriptive study was conducted to explore the experiences and coping mechanisms of nurses regarding workplace violence. The purposive sample comprised eight nurses working in the Trauma and Emergency Department in the Western Cape, South Africa. Thematic analysis was done of the semi-structured interviews. Four main themes and 10 categories were identified. Nurses are experiencing physical threats, verbal abuse and psychological and imminent violence on a regular basis. They tend to ‘normalise’ abusive patient behaviour because of the perception that workplace abuse ‘comes with the territory’, which resulted in under-reporting. However, perpetrators received compromised care by being avoided, ignored or given only minimal nursing care. Coping mechanisms ranged from using colleagues as sounding boards, helping out with duties, taking a smoke break and using friends and family to get it ‘off their chest’. The tolerance of non-physical violence and the absence of policies to deal with the violence, contribute to under-reporting.Geweld in die Suid-Afrikaanse samelewing het epidemiese vlakke bereik en selfs werksplekke binnegedring. Die doel van die studie was om ‘n dieper begrip te verkry van hoe verpleegsters geweld deur pasiënte by die ​​werksplek ervaar en verstaan, en aanbevelings te maak om hierdie tipe van geweld te verminder. ‘n Kwalititatiewe, eksploratiewe en beskrywende ontwerp is gebruik om die ervaringe en hanteringsmeganismes te verken van verpleegkundiges wat aan werkpleksgeweld blootgestel was. ‘n Doelgerigte steekproef is gedoen bestaande uit agt verpleegkundiges werksaam in die Trauma en Nooddienste Departement in die Weskaap, Suid Afrika. Die semi-gestruktureerde onderhoude is kwalitatief ontleed vir temas. Vier hooftemas en 10 kategorieë is geïdentifiseer. Verpleegkundiges ervaar dreigemente van fisiese geweld, verbale misbruik en psigiese en dreigende geweld gereeld. Hulle is geneig om pasiënte se misbruikende gedrag te ‘normaliseer’ omdat hulle die persepsie het dat geweld of misbruik ‘deel van die werksomgewing’ is. Hierdie persepsie gee aanleiding tot onder-rapportering van nie-fisiese geweld en gekompromitteerde sorg deurdat skuldige pasiënte of vermy, geïgnoreer of minimale sorg gegee word. Hanterings meganismes sluit in reflektering teenoor kollegas, uithelp met take, die gebruikmaking van ’n rook breek, en ontlaaing teenoor familielede en vriende. Die toleransie van nie-fisiese geweld en die gebrek van beleidsriglyne dra by tot die onder-rapportering van werksplek geweld.