Abstract Objective Special observation (the allocation of nurses to watch over nominated patients) is a method of preventing patients harming themselves. This study assessed the relationship between ...constant special observation (keeping a patient within eyesight or reach) and rates of self-harm on acute psychiatric wards. Method A longitudinal analysis of officially collected data covering a period of 2 1/2 years from 16 acute wards at three Hospitals in London. Results There was no statistically significant association between constant special observation and self-harm outcomes. Use of observation varied markedly between hospitals and wards, but overall, there was a significant decline over time. Self-harm incidents were rare (recorded in only 7% of ward weeks) and did not decline over time, but were correlated over consecutive weeks. Conclusion The lack of association with self-harm suggests that the use of constant special observation could be reduced without compromising patient safety.
Background. Violence in nursing is not a new phenomenon but in recent years much greater emphasis has been placed on the problem in the United Kingdom (UK). A number of official reports, media ...stories and national initiatives have focused attention on the problem in this country. However, it is not clear whether violence and abuse have in fact become more prevalent. At present little is known about the scale of the problem for general nurses working in general hospitals in the UK.
Aim of the study. A realistic assessment of the scale of this problem should facilitate a meaningful debate about the interventions needed to counter it and support the requests for funding that will be required. This study aimed to establish the utility of existing research findings, to include relevant but previously unused sources and to synthesize the results.
Method. A systematic search of the literature pertinent to the aim of the study was followed by a critical review. The focus was on research originating in the UK, including some general research on occupational violence which included data on nurses.
Findings. Overall, the research findings are limited. The best available evidence suggests nurses as a whole do face a high level of risk compared with all workers and this excess risk holds for general nurses. The data support a figure of more than 9·5% of general nurses working in general hospitals assaulted (with or without injury) in any 1 year. Trends over time are impossible to identify at present.
Conclusions. Efforts to combat the problem should include greater emphasis on the problem outside accident and emergency departments, prioritizing preregistration training in the management of aggression, and further research. Better reporting should also be a priority.
Therapeutic and informal interactions with nurses are integral to the quality of care that psychiatric patients receive. How well these interactions are performed, and their impact on the experience ...and outcomes of inpatient care, have not been subject to systematic evaluation. The aim of the present study was to examine patients' perceptions of the personal and professional qualities of nursing staff and how these contribute to the ward environment. Patients (n = 119) from 16 acute psychiatric wards were interviewed using a schedule developed by a service‐user researcher. Transcriptions of interviews were coded and organized into six themes: staff duties, staff disposition, control, communication and engagement, therapeutic ward environment, and consistency. Patients recognized that nurses have a difficult and stressful job, but frequently expressed feelings of anger, frustration, and hopelessness about their experience of the wards. Patients frequently felt that nursing staff did not understand issues from their perspective or attempt to empathize with them. The findings indicate poorly‐communicated and inconsistent care. Initiatives to improve patients' experiences of acute psychiatric wards are urgently needed.
Conflict (for example, aggression, substance use, and absconding) threatens the safety of patients and staff, and containment use (for example, coerced medication, special observation, and manual ...restraint) arouses strong feelings and is controversial. Previous work suggests that three staff factors have an impact on rates of these events: the positive appreciation of patients by staff, the staff's management of their own emotional reactions to patient behavior, and the provision of an effective structure. The aim of this study was to test this theory.
A multivariate cross-sectional design was utilized. Data were collected for a six-month period on 136 acute psychiatric wards in 26 National Health Service Trusts in England. Multiple regression was conducted to determine the factors most strongly associated with total conflict and containment rates.
Provision of an effective structure of rules and routines for patients was the staff feature most strongly and consistently associated with lower conflict and containment rates, with other elements of the theory less well supported by the data. Other patient and ward factors were also significantly associated with differences in conflict and containment rates between wards, in particular the proportion of patients formally detained under mental health legislation, the quality of the physical environment, and staff and patient race-ethnicity.
Conflict and containment are reliable and meaningful concepts. Staff factors are relevant in the determination of conflict and containment rates on wards, but the most important of these is the provision of an effective, well-organized structure of rules and daily routines. There are a number of ways in which conflict on wards might be reduced, including a greater emphasis on the production of effective structure and order on the ward and work in the community to reduce the numbers of compulsory admissions.
Abstract Objective This study aims to (a) describe what conflict (aggression, absconding etc.) and containment (de-escalation, restraining etc.) events occur before and after events of medication ...nonadherence on acute psychiatric wards and (b) identify which patient characteristics are associated with medication nonadherence. Method Conflict and containment events for each shift over the first 2 weeks of admission were coded retrospectively from nursing records for a sample of 522 adult psychiatric inpatients. The frequency and order of the conflict and containment events were identified. Univariate logistic regression models were conducted to examine which patient characteristics were linked with medication noncompliance. Results Medication refusals were commonly preceded by aggression whereas demands for pro re nata (PRN) (psychotropic) were commonly preceded by the same patient having been given PRN medication. Refusals and demands for medication were commonly followed by de-escalation and given PRN (psychotropic) medication. Only refusal of PRN medication was commonly followed by forced (intramuscular) medication. Ethnicity, previous self-harm and physical health problems were also linked to nonadherence. Conclusions Greater attention to the conflict and containment events that precede and follow medication nonadherence may reduce the likelihood of medication nonadherence.
Acute psychiatric wards manage patients whose actions may threaten safety (conflict). Staff act to avert or minimise harm (containment). The Safewards model enabled the identification of ten ...interventions to reduce the frequency of both.
To test the efficacy of these interventions.
A pragmatic cluster randomised controlled trial with psychiatric hospitals and wards as the units of randomisation. The main outcomes were rates of conflict and containment.
Staff and patients in 31 randomly chosen wards at 15 randomly chosen hospitals.
For shifts with conflict or containment incidents, the experimental condition reduced the rate of conflict events by 15% (95% CI 5.6–23.7%) relative to the control intervention. The rate of containment events for the experimental intervention was reduced by 26.4% (95% CI 9.9–34.3%).
Simple interventions aiming to improve staff relationships with patients can reduce the frequency of conflict and containment.
IRSCTN38001825.
People with personality disorders are to be found in all branches of psychiatric services, from the outpatient and community care through to acute inpatient care. Their behaviour is difficult, ...manipulative, threatening and they are hard to manage in institutional settings. Dangerous and Severe Personality Disorder is based on unique research study conducted in the three English high security hospitals - Ashworth, Rampton and Broadmoor. Through in-depth analysis of an extensive questionnaire survey followed by personal interviews, Len Bowers shows how positive or negative attitudes to PD patients arise and are maintained over time, as well as discusses what impact they have upon nurses and the care they provide to patients, and draws some practical conclusions.
The difficulties facing staff who care for and treat PD patients are enormous, and constitute a significant personal challenge for the psychiatric professional of any discipline. For the first time this book provides details of the most effective ways of creating a positive context for working with personality disorder and contains a blueprint for training and organisational structures across the professional spectrum.
'This is a humane and sensible analysis of this complex and contested territory, and an account of forensic nursing practice that is a powerful antidote to some of the more damning critical press of recent years.' - Mick Mckeown, Mental Health Today 'Bowers presents passionate and challenging observations made in the style of his earlier work, and provokes readers to look within themselves to reveal a deeper understanding of some of the issues raised.' - Mental Health Practice
1. 'Welcome to the World of PD' 2. 'Special Hospital Country' 3. Trials and Tribulations 4. Staying Positive 5. A Supportive Organisation and Team 6. Effects and Impacts 7. Us and Them
Abstract Objective This article aimed to explore the relationship of medication-related conflict refusal of regular medication, refusal of pro re nata (prn) medication, demanding prn medication to ...other conflict behaviours, the use of containment methods, service environment, physical environment, patient routines, staff demographics and staff group variables. Method The Patient-staff Conflict Checklist (PCC-SR), an end-of-shift report completed by nurses on the frequency of conflict and containment events, was collected for a 6-month period on 136 acute mental health wards in 67 hospitals within 26 NHS Trusts in England, in 2004–2005. Multilevel modelling was used to assess associations with medication-related conflict rates. Results The mean daily rate (at ward level, standardised to 20 beds) of incidents of regular medication refusal was 0.89 (S.D. 0.52), prn medication refusal 0.30 (S.D. 0.19) and demanding prn medication 1.09 (S.D. 0.63). The frequency of these events was found to be associated with passive resistant patient behaviours, higher levels of containment (specifically locking the main ward door, the use of special observation, and time out) and unstable staffing profiles. Conclusion It may be possible to achieve greater medication concordance amongst patients in acute mental health wards through a more consensual approach to care. Paradoxically, fewer restrictions may promote better treatment acceptance and safer outcomes. Consistent nurse staffing and therefore better staff–patient relationships are also likely to improve cooperation and outcomes.
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