Article

Violent Incidents in a Secure Service for Individuals with Learning Disabilities: Incident Types, Circumstances and Staff Responses

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Abstract

Background: The issue of violence in secure services has long been recognised both in the UK and worldwide. However, there is currently scarce literature available about violence within Learning Disability (LD) secure settings. Methods: Secondary data analysis was conducted on violent incidents, using information routinely collected by the staff over a one-year period. Results: Physical assaults were the most frequent type of incident, the distribution in terms of days or months was homogenous and incidents were concentrated in the corridors, lounges, and dining rooms of secure facilities. Antipsychotic medication was not regularly prescribed. Generalised linear modelling analyses revealed significant predictors that increased the chances of seclusion and physical restraint, such as being female or directing the violence towards staff. Conclusions: These findings can inform staff training on violence prevention, and suggest that increased ward-based supervision and enhanced use of psychological formulations may help in reducing violence within this service context.

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... Twenty-two peer-reviewed articles around issues of risk in U.K. inpatient forensic settings for people with an intellectual disability were deemed suitable for inclusion. Of these, seven were quantitative/experimental designs (Campbell & McCue, 2013;Chester et al., 2017Chester et al., , 2018Fitzgerald et al., 2013;Hogue et al., 2007;Morris et al., 2021;Novaco & Taylor, 2015), five were qualitative (Duperouzel & Fish, 2010;Lovell et al., 2014;Malda-Castillo et al., 2018;Wright et al., 2014;Wood et al., 2008), four cohort studies (Russell et al., 2018;Lindsay, Carson, et al., 2013;Lindsay et al., 2012), There were two service evaluations/ audits (Alexander et al., 2015;Plant et al., 2011), two survey designs (Fish et al., 2012;Mason et al., 2011), one case study (Ashworth et al., 2020) and one study utilising the Delphi approach (Morrissey et al., 2017). (4) looking to the future. ...
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Background: People with an intellectual disability who commit a criminal offence can be detained, by a court, in a forensic inpatient facility. There is limited understanding of how inpatients with an intellectual disability and their nurses navigate risk in U.K. forensic services. Methods: A traditional literature review design was followed to map evidence (2000-2021) around the forensic and health and wellbeing risks faced by inpatients with an intellectual disability, nurses' perceptions of managing risk, and patient experiences of informing risk assessment and management. Papers were analysed thematically. Results: Findings suggest that restrictive measures to mitigate forensic risks (e.g., violence) can exacerbate the risk of poor health and wellbeing outcomes. There was some limited evidence of direct patient involvement in risk assessment and management. Conclusion: Further research is required to explore how forensic inpatients with an intellectual disability can have input in care planning, risk assessment and management.
... Thus, for people with intellectual disabilities in secure settings, and those at risk of detention, aggression and violence should be primary therapeutic targets. Especially as the rates of continued aggression and violence in these settings is very high (Malda Castillo et al., 2018;Taylor et al., 2016) and is therefore likely to be a significant factor in increasing length of detention and preventing discharge to community settings. ...
... Open access BACKGROUND Incidents of violence and aggression are a serious concern for mental health services and evidence suggests QI methods can be an effective tool to examine and implement changes to reduce violence in mental health and secure settings. 1 2 Recent research found physical assaults to be the most common form of incidents on an intellectual disability secure ward, 3 and incidents of violence and aggression are most likely to be managed through a number of physical and restrictive practices, including restraint, seclusion and medication. 4 The ethics of using physical and restrictive interventions have been contested by researchers, policymakers and advocacy groups, with these interventions often described as aversive and traumatising while also proving ineffectual in creating long-term behavioural change. ...
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Incidents of violence and aggression are serious concerns on a secure ward for people with intellectual disabilities and are often met with increases in physical and restrictive interventions. However, these interventions are usually high risk for both patients and staff and are ineffectual in promoting long-term behaviour change. This study aimed to promote positive culture change and embed the evidence-based practice of positive behaviour support by shifting focus and efforts from the use of physical and restrictive interventions to manage crises to intervening positively and proactively to prevent crises from occurring. The key drivers for change involved increasing access to positive engagement opportunities, expanding the staff team’s repertoire of proactive interventions through training and skill development and supporting staff well-being and resilience. Change ideas occurred alongside a shift in culture that promoted the development of a learning culture, psychological safety and consideration of contextual fit. Quality improvement methods helped the project increase the rate of positive and proactive interventions from 70.65% in December 2018 to 97.18% in January 2020. Increases in staff’s knowledge, confidence and safety were also reported. Lessons and limitations of the project are discussed.
... Thus, for people with intellectual disabilities in secure settings, and those at risk of detention, aggression and violence should be primary therapeutic targets. Especially as the rates of continued aggression and violence in these settings is very high (Malda Castillo et al., 2018;Taylor et al., 2016) and is therefore likely to be a significant factor in increasing length of detention and preventing discharge to community settings. ...
... England under the Mental Health Act 1983 on the basis of their 'abnormally aggressive' and/or 'seriously irresponsible' behaviour (Health & Social Care Information Centre, 2014).Once admitted, people with intellectual disabilities are likely to remain in hospital for extended periods compared with non-disabled detentionsfive times longer for men and 11 times longer for women (Care Quality Commission, 2011).Thus, for people with intellectual disabilities in secure health care settings aggression and violence should be primary therapeutic targets. Especially as the rates of continued aggression and violence in these settings is very high(Malda Castillo et al., 2018;Taylor, Commentary on PBS in Secure Settings 9 ...
... 4 Ook kunnen dergelijke gegevens dienen voor planning en veiligheidsbeleid van instellingen. 5 In de context van een pandemie zijn met name incidenten rondom agressie en onverklaarde afwezigheid van belang. ...
... Reports may also include near-incidents, where timely interventions prevented the incident from occurring. Incident reports of aggression in particular have shown to be related to clinical risk assessment for aggression (O'Shea et al. 2015) and to be a helpful tool for care facilities to take measures towards guarding safety (Malda Castillo et al. 2018). ...
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Background: The lockdown-measures in response to COVID-19 taken by long-term care organisations might have impacted problem behaviour and behavioural functioning of people with intellectual disability. This study tested changes in reported incidents, in particular regarding aggression, unexplained absence and, for contrast, medication errors. Methods: Metadata on weekly incident and near-incident reports from 2016 to June 2020 involving over 14 000 clients with mild to serious intellectual disability of 's Heeren Loo, a long-term care organisation for people with intellectual disability, were subjected to interrupted time series analysis, comparing the COVID-19 with the pre-COVID-19 period. Results: The imposition of lockdown-measures coincided with a significant drop in incidents (total, P < .001; aggression, P = .008; unexplained absences, P = .008; and medication errors, P < .001). Incidents in total (P = .001) and with aggression (P < .001) then climbed from this initial low level, while medication errors remained stably low (P = .94). Conclusion: The rise in incidents involving aggression, against the background of generally lowered reporting, underlines the need for pandemic control measures that are suitable for people with intellectual disability in long-term care.
... This, according to some authors, has resulted in an under-estimation of the role of early traumatic experiences, particularly with regard to how this might influence impulse control ability in later life (Marshall et al., 2016). Similarly, there has been plenty of interest in the role of anger and an individual's previous involvement in violence, and not enough around examining the particular circumstances, such as the location of an incident (Malda Castillo, Smith, Morris, & Perez-Algorta, 2018), or the hypersensitivity to touch or noise that may disproportionately affect people with learning disabilities (Lillywhite & Haines, 2010). The significance of the role of specific conditions, however, such as borderline personality disorder (BPD), autism spectrum conditions (ASC) and psychosis, with regard to early life history, should not be under-estimated, with strong evidence that they frequently emerge in the context of traumatic experiences of neglect, abuse and violence (World Health Organisation, 2012). ...
Article
Accessible Summary • The role of an individual's personal history is important in influencing their development, especially whether they are likely to offend or engage in violent behaviour • Learning disability nurses relationships with those with a history of violence or offending will improve with a more informed knowledge of how someone's offending behaviour is related to their background • People with a learning disability can be supported best when the complexity of their lives is fully understood and properly informs the therapeutic relationship. Abstract 1.1 Background There is growing recognition that an individual's personal history can be extremely influential in shaping their future experience, though there has been a limited exploration in the context of learning disability and offending behaviour. 1.2 Method Research questions related to participant interpretation of offending behaviour and individual and service responses. A series of focus groups comprising learning disability forensic nurses were conducted across all secure settings, high, medium and low. 1.3 Results Three themes were produced: interpreting offending behaviour; the impact of personal history; responding therapeutically. The difficulties relating to understanding the relationship between offending behaviour and personal history significantly informed the construction of the most effective therapeutic relationships. 1.4 Conclusions An increased focus on the impact of someone's background might inform nursing as it seeks to deliver care to individuals with increasingly complex needs in a time of service transition.
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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. Crown Copyright © 2015. Published by Elsevier Ltd. All rights reserved.
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Introduction We examined physical violence in a large, multihospital state psychiatric system during 2011-2013, and associated demographic and clinical characteristics of violent patients to better understand issues of patient and staff safety. Acts of physical violence committed by patients against other patients (n=10,958) or against staff (n=8429) during 2011-2013 were collected and analyzed for all hospitalized patients during the same time period to derive prevalence rates and associated odds ratios. Overall, 31.4% of patients committed at least 1 violent assault during their hospitalization. Differential risk factor patterns were noted across patient and staff assault. Younger age was associated with a higher prevalence of both patient and staff assault, as was nonforensic legal status. Females had a higher prevalence of staff assault than patient assault. Ethnic groups varied on rates of patient assault, but had no significant differences for staff assault. Schizoaffective disorder was associated with higher prevalence and odds of patient (OR 1.244, 95% CI 1.131 to 1.370) and staff (OR 1.346, 95% CI 1.202 to 1.507) assault when compared to patients diagnosed with schizophrenia. Most personality disorder diagnoses also had a higher prevalence and odds of physical violence. One percent of patients accounted for 28.7% of all assaults. Additionally, violent patients had a significantly longer length of hospitalization. Discussion Implications of these findings to enhance patient safety and inform future violence reduction efforts, including the need for new treatments in conjunction with the use of violence risk assessments, are discussed.
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The aim of the study was to examine learning disability nurses' perceptions of incidents involving physical intervention, particularly factors contributing to injuries sustained by this group. This article reports on a qualitative study undertaken within one secure NHS Trust to respond to concerns about staff injuries sustained during physical interventions to prevent incidents of service user violence from escalating out of control. The context of the study relates to increasing debate about the most effective approaches to incidents of violence and agression. A qualitative research design was utilized for the study. Semi-structured interviews were undertaken with 20 participants, two from each of the 10 incidents involving staff injury sustained during physical intervention. Four themes were produced by the analysis, the first, knowledge and understanding, contextualized the other three, which related to the physical intervention techniques employed, the interpretation of the incident and the impact on staff. Service user violence consistently poses nurses with the challenge of balancing the need to respond in order to maintain the safety of everyone whilst simultaneous supporting and caring for people with complex needs. This study highlights the need for further exploration of the contributory factors to the escalation of potentially violent situations. Services may have good systems in place for responding to and managing service user violence but appear less effective in understanding the reasons for and developing strategies to prevent violence occurring. © 2015 John Wiley & Sons Ltd.
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Purpose ‐ The purpose of this paper is to describe how aggressive and violent incidents differ across specialist gender, security and mental health/learning disability pathways in specialist secure care. Design/methodology/approach ‐ The paper uses a retrospective survey of routinely collected incident data from one 207-bed UK independent sector provider of specialist medium and low secure mental health care for male and female adults with primary diagnosis of mental illness or intellectual disability. Findings ‐ In total, 3,133 incidents involving 184/373 (49.3 per cent) patients were recorded (68.2 per cent other-directed aggression, 31.8 per cent self-harm). Most incidents occurred in the medium secure wards but more than half of the most severely rated self-harm incidents occurred in low security. Men were disproportionately involved in incidents, but a small number of women were persistently involved in multiple acts. Incidents were most common in the intellectual disability pathway. Research limitations/implications ‐ Incidents, especially those of lower severity, can be under-reported in routine practice. Information about incident severity was limited. Practical implications ‐ Aggressive incidents do not occur homogenously across forensic and secure mental health services but differ substantially in their frequency and nature across security levels, and gender and mental health/intellectual disability pathways. Different approaches to training and management are required to ensure appropriate prevention and intervention. Future practice should draw on emerging theories of differential susceptibility. Originality/value ‐ This paper extends current knowledge about how incidents of violence and aggression differ across secure settings.
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The study examines the experiences of physical restraint procedures reported by nursing staff in a secure mental health service. Interview data were subjected to thematic content analysis in accordance with grounded theory methodology.Nursing staff reported a range of emotional responses to the use of restraint procedures. They included anxiety, anger, boredom, distress and crying. In some cases these responses were confirmed by descriptions from patients.Staff coped with the emotional responses to restraint in a variety of ways. Some staff discussed the ‘stigma’ attached to showing feelings to other staff. They described how laughter was used to reduce stress following an incident and how distressing emotions had to be taken home. Some staff described how they had become ‘hardened’ to the experience of restraint. A substantial proportion of staff suggested that they had ‘no’ emotional reactions and many reported ‘automatic’ responding during a restraint event in which they did not feel any emotion.Possible implications of these responses and clinical practice are discussed.
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Several studies have provided strong evidence that personality disorders (PD) represent a significant clinical risk for violence. This review has aimed to examine the relationship of greater risk for violence among persons with certain PD in terms of four fundamental personality dimensions: 1) impulse control; 2) affect regulation; 3) threatened egotism or narcissism; and 4) paranoid cognitive personality style. Two of these dimensions -impulse control and affect regulation- are probably substantially affected by virtually all PDs linked to violence. Narcissism or threatened egotism and paranoid cognitive personality style have also been empirically linked to violence and mental disorder. PD symptoms have proven to be even stronger predictors of violence than the PDs per se. In fact, increased symptoms of DSM-IV cluster A or cluster B PD, such as paranoid, narcissistic and antisocial PD symptoms, correlate significantly with violence. Finally, there are three important principles about the relationship between PDs and violence: 1) PDs are rarely egosyntonic; 2) most patients and violent situations that come to clinical attention involve comorbid conditions; and 3) violence and risk of violence are often associated with substance abuse. Implications of this review for further research are discussed.
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Background: Antipsychotic medications have been used extensively to treat aggressive behaviours in persons with intellectual disabilities (ID) when the main psychiatric diagnoses given to them in the past were schizophrenia, childhood psychoses and ID with behaviour problems. Today, antipsychotics are still estimated to comprise 30-50% of all the psychotropics prescribed for persons with ID, although the prevalence of psychotic disorders is only 3% in this population. The overuse of antipsychotics in persons with ID could be justified if their aggressive behaviours were associated with mostly psychotic disorders and not other psychiatric disorders or factors and if the anti-aggressive properties of the antipsychotics have been supported by basic research or reviews of clinical studies. Is that so? This article explores these questions. Methods: The literature on aggressive behaviours, their associations with psychiatric disorders and other contributing factors and the past and current treatment options for aggressive behaviours in persons with and without ID was reviewed. Also, the literature on basic research regarding the brain receptors implicated in aggressive behaviours and the basic research and clinical studies on the anti-aggressive properties of antipsychotics was reviewed. Results: Aggressive behaviours in persons with ID serve different functions and many factors contribute to their initiation, maintenance and exacerbations or attenuation including most of the psychiatric and personality disorders. Genetic disorders, early victimisation, non-enriched and restrictive environments during childhood or later on and traumatic brain injury, which are common in persons with ID, have been associated with aggressive behaviours and with mostly non-psychotic disorders in persons with and without ID. If the factors above and the knowledge derived from studies of domestic violence and premeditated aggression in persons without ID are considered and applied during the evaluation of the most severe aggressive behaviours in persons with ID, more appropriate and effective treatment than antipsychotics can be implemented. Basic research implicates mostly the GABA and the serotonin pre-post synaptic brain receptors influence the initiation, modulation or inhibition of aggression in animals. The anti-aggressive properties of the antipsychotics have not been supported by reviews of clinical studies and basic research is absent. Antipsychotics are the indicated treatment only for psychiatric disorders and for aggressive behaviours associated with psychotic disorders and psychotic features as activation of dopamine receptor leads to defensive aggression. Conclusions: Most of the persons with ID and aggressive behaviours do not have a diagnosis of psychotic disorder and there is lack of strong evidence supporting the anti-aggressive properties of the antipsychotics. The overuse of antipsychotics in this population may be explained by the old, faulty notion that aggressive behaviour in persons with ID is mostly associated with psychotic disorders. Given the discrediting of this notion, the use of antipsychotics in persons with ID may, in some cases, be considered mistreatment rather than proper treatment. In order to reverse the practice of over-prescribing antipsychotics for aggressive behaviours in persons with ID, basic research information on aggression must be disseminated, the search for the 'quick fix' must be abandoned and the promotion of antipsychotics as anti-aggressive drugs must be discouraged. Matching the treatment with the variables contributing to the aggressive behaviours, seeking a long-term rather than a short-term solution and avoiding the promotion of only one type of treatment for all types of aggression might change the current practice and improve the quality of life for many persons with ID.
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Improved risk assessment has been stressed as the way to reduce homicides by people with mental illness. The feasibility of predicting rare events needs examining. To examine the findings of public inquiries into homicides by people with mental illness to see if they support the claim that better risk assessment would have averted the tragedy. Analysis was made of the findings of the public inquiries between 1988 and 1997 in relation to the predictability and preventability of the homicides. Of the homicides considered by the inquiry panels, 27.5% were judged to have been predictable, 65% preventable and 60% of the patients had a long-term history containing violence or substantial risk factors for violence. Improved risk assessment has only a limited role in reducing homicides. More deaths could be prevented by improved mental health care irrespective of the risk of violence. If services become biased towards those assessed as high risk, then ethical concerns arise about the care of both violent and non-violent patients.
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Treatment of patients with personality disorder remains controversial and severe mental illness is prioritized in secure forensic psychiatry services. To compare patients with personality disorder and mental illness according to demography, referral, criminality, previous institutionalisation and diagnostic comorbidity. A record survey of 511 patients with personality disorder and 2575 with mental illness admitted to secure forensic psychiatry services between 1 January 1988 and 31 December 1994 from half of England and Wales. Personality disorder admissions declined over time; more were female, White, younger and extensively criminal (specifically, sexual and arson offences). Personality disorder was highly comorbid; antisocial, borderline, paranoid and dependent personality disorder were most prevalent. Patients with personality disorder were highly selected and previously known to psychiatric services. Referrer, diagnostic comorbidity and behavioural presentation determined their pathways into care. Future research must determine whether their continuing admission represents effective use of scarce resources and whether new services are required.
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Patient-related incidents are of particular concern for those working with forensic psychiatric populations. Evidence suggests that personality, stress, and burnout of nursing staff are predictive of incidents. However, the exact relationship of these factors with staff-patient interactions and the incidents that occur within these interactions have not been thoroughly explored. The authors collected data on the nature of incidents on a forensic unit within a psychiatric hospital over a 1-year period, as well as data on the characteristics of 13 staff members. They found that 10% of patients were responsible for 58% of the incidents. Patients with a diagnosis of schizophrenia were disproportionately involved in incidents. The frequency of non-violent incidents varied among nursing teams to an extent greater than that expected by chance. A relationship between incidents and some staff characteristics was also found. These results highlight the need for further research into the incidents that occur in situations where patient attributes, nurse attributes, and environmental factors produce complex interactions.
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Aggressive behaviour is a problem for services providing care for people with intellectual disabilities, affecting the quality of life of the individual and the quality of care provided. Current research trends, which focus on risk factors and mental health problems, are discussed. Other factors that could contribute to aggression in people with intellectual disability (PWID), such as lifestyle and environmental issues are examined. A methodology that would allow for the integration of all these factors, Behavioural Sequence Analysis, is a suitable investigative approach to this problem.
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• Of 638 reported assaultive and disruptive incidents in 1979 in a maximum security hospital, 221 (34.6%) were batteries. Whether an incident was a battery or not was a function of time and location. Preludes to battery were noted by staff in only 23.1% of cases and were high-frequency behaviors with low predictive value. Impact and injury to patients and officers occurred through both batteries themselves and efforts to subdue the batterer. With length of hospitalization controlled, the distributions of preadmission criminal charges were not significantly different between batterers and controls. Policies that alter patterns in the timing and location of interaction among patients and in the response of officers or other personnel to batteries in progress offer promise for reducing incident and injury rates.
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A study of the number, perpetrator, time and target of violent behaviour was carried out in a Finnish state forensic psychiatric hospital, Vanha Vaasa Hospital?Gamla Vasa Sjukhus. Forensic psychiatric patients and patients difficult-to-treat are treated in the hospital. According to the results the number of violent incidents has been quite small in the hospital during the time of the study in relation to violence in similar units and hospitals. The patients treated on account of their dangerousness and difficult propensities were the most violent, not the patients who had been charged with their violent acts. Only a small number of the patients behaved violently in the hospital. The relative number of violent female patients was larger than that of the male patients. Trained nurses and the patients themselves were found to be more often the target of the violent behaviour of particularly violent patients, whereas less violent patients directed their aggressiveness against objects. Violent incidents were more frequent during nights and at the time of patients' activities, but especially during the change of working shifts. The fewest violent incidents occurred in autumn.
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A correlational survey of violent incidents using a descriptive, retrospective design and quantitative data analysis showed that the large majority of violent incidents in an adolescent forensic unit were generated by young people with no prior offending history. The most violent young people were characteristically psychotic and conduct-disordered, and presented with high risk and challenging behaviour. By contrast, a small minority of violent incidents were generated by mentally disordered young offenders with a history of seriously violent behaviour including murder, attempted murder and manslaughter. A training needs analysis is presented which will inform a strategy for the management of aggression and violence in young people.
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ACCESSIBLE SUMMARY: Over half of the violent incidents considered in this study were unexplained. The risk for violent behaviour inside the hospital was the highest for civil patients. The risk rate in this group was 12 compared to criminal patients' risk rate of one. ABSTRACT: The aim of this paper was to explore the frequency and provocation of physically violent incidents in a Finnish forensic psychiatric hospital. Three years (2007-2009) of violent incident reports were analysed retrospectively. The data were analysed by content analysis, and statistically by Poisson regression analysis. During the study period a total of 840 incidents of physical violence occurred. Six main categories were found to describe the provocation of violence where three of these categories seemed to be without a specified reason (61%), and three represented a reaction to something (36%). The risk for violent behaviour was highest for the civil patients (RR = 11.96; CI 95% 9.43-15.18; P < 0.001), compared to criminal patients (RR = 1). The civil patients represented 36.7% of the patients, and in 43.6% of the studied patient days, they caused 89.8% of the reported violence incidents. Patients undergoing a forensic mental examination did not frequently behave aggressively (RR = 1.97; CI 95% 0.91-4.28). These results can be used in the reorganization of health-care practices and the allocation of resources.
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The cognitive behavioural treatment for anger in adults with intellectual disabilities has received increasing interest. The current study aims to review the current literature and provide a meta-analysis. A literature search found 12 studies eligible for the quality appraisal. The studies examined cognitive behavioural treatment for anger in adults with intellectual disabilities published since 1999. Nine studies were eligible to be included in the meta-analysis. The meta-analysis revealed large uncontrolled effect sizes for the treatment for anger in adults with intellectual disabilities, but is viewed with caution due to low sample sizes. The narrative review showed improved methodological quality of the literature. The emerging literature is encouraging. However, it is limited through concatenated data, a lack of comparative control groups and small study samples.
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The aggressive behaviour of psychiatric inpatients has profound consequences for patients, staff, ward atmosphere and psychiatric hospitals in general. Considerable international research exists, primarily conducted in general psychiatric hospitals, on the prevalence and determinants of aggression. Conclusions drawn from this research contribute valuable information about the clinical and demographic characteristics of aggressive patients. There is little Australian research available, however, that contributes directly to aggression management and minimization strategies for local facilities. Furthermore, no published research on aggression in an Australian forensic psychiatric hospital exists. Australian research is required because of the clear influence of situational and cultural contributors to aggression. The aim of this project was to review retrospectively documented incidents of aggression that occurred during the first year of operation of the Thomas Embling Hospital, a forensic psychiatric hospital in Victoria, Australia. Results showed that aggression was prevalent although most likely there was an underestimate of verbal and physical aggression. Acute wards recorded almost 90% of incidents. Proportionately, males and females were similar in both the frequency and type of aggression. Males tended to be aggressive towards males and females were aggressive towards females. Variations in the patterns of physical aggression across wards were found. These variations may have been a consequence of differences in aggression management strategies, particularly the tendency to use restraint and seclusion. The use of seclusion to contain actual or potentially aggressive patients may contribute to more frequent aggression and injury to staff since the staff were more frequently the victims of physical aggression during restraint than by direct assault.
Article
The main objective of this study was to identify the factors that differentiate persistently violent patients from less violent patients. Violent incident forms completed between 1980 and 1996 on the Denis Hill Unit, a medium secure unit, at the Bethlem Royal Hospital were analysed. During this period 280 patients were admitted to the unit and of those 165 (59%) had one or more violent incidents recorded against them. Out of a total of 2,180 incidents 1,460 (67%) were accounted for by 18 (6%) of the patients, who each had 25 or more violent incidents during their stay on the Unit. Of these 18 patients, additional background and outcome data were available on 17 patients. The 17 patients were compared with their less violent peers (i.e. those with fewer than 25 violent incidents) using the maximum number of variables that were available for analysis. A stepwise logistic regression revealed three significant variables in the final model. The odds were 5 : 1 against the persistently violent patients having received previous prison sentences, almost 5 : 1 in favour of them being female and 3 : 1 of them having had a history of special education. The findings have important resource and management implications for those persistently violent patients.
A retrospective survey was conducted of the prescribing practices of child and adolescent psychiatrists serving both inpatients and outpatients in one health region of 2.5 million population. The majority of psychiatrists were found to prescribe - 87% (21/24) a ratio of 7:1. The most commonly treated disorders were: psychoses, depression and hyperactivity. There has been a recent shift in prescribing practice for antidepressants, with the introduction of the newer selective serotonin re-uptake inhibitors (SSRIs). The number of patients treated was small and appears comparatively less than in the US.
Article
Background There is a high rate of physical violence in populations with intellectual disabilities, and this has been linked to problems for the victim, the assailant, members of staff and services. Despite the clinical significance of this behaviour, few studies have assessed methods of predicting its occurrence. The present study examined clinical and actuarial methods of predicting violence in a forensic intellectual disability hospital. Methods The sample for the study consisted of people resident in the hospital during a 1-year period (n = 124). Clinical prediction used a risk rating made by members of the person's clinical team, whereas actuarial prediction used the number of violent incidents in the 6-months before the date of the clinical risk assessment. Computerized hospital records of violence in the 6 months after the assessment were used to examine the predictive accuracy of the two methods. Results The clinical method produced an area under the curve of 0.74 (95% CI: 0.65–0.83) in a receiver–operating characteristic curve analysis. The value for the actuarial method was 0.77 (95% CI: 0.69–0.86). Both methods performed at levels significantly above chance, but no one method was found to be superior to the other. Conclusions These findings suggest that it is possible to predict who is at risk of violence in forensic populations with intellectual disabilities. Here, the authors discuss the clinical implications of these findings and the clinical application of risk prediction within clinical services.
Article
Limit-setting and de-escalation are commonly used nursing interventions that are critical to the effective maintenance of the therapeutic milieu and the prevention and management of aggression in forensic mental health units. However, despite their purported importance, the techniques used in these interventions are rarely described. Further, these techniques are seldom based on empirical research or derived from a theory or model of aggression or interpersonal behavior. The purpose of this review is to examine the extant literature on limit-setting and de-escalation and consider how these activities could be enhanced. In concluding, this review emphasizes the potential benefits of drawing upon (1) a model of aggressive behavior and (2) a theory and literature examining interpersonal behavior, to enhance limit-setting and de-escalation skills.
Article
There has been increased research in recent years on incidents within adolescent inpatient psychiatric units, although findings to date have been somewhat inconsistent. We analysed all reported incidents by 37 consecutively discharged patients from a mixed sex adolescent forensic hospital. Findings include a very high overall rate of incidents. A small number of female patients with emerging emotionally unstable personality disorder accounted for the majority of violent incidents and other incidents. Almost all the patients assaulted someone during their admission. Patients on civil sections of the Mental Health Act had just as many incidents as patients on forensic sections. The vast majority of assaults were on staff. Peak times for incidents were the end of each day when education sessions were timetabled and the beginning of the night shift.
Article
This study explores the issue of violence experienced by staff in the learning disability service of an NHS Trust. Based on the literature review a questionnaire survey was sent to all staff employed in the Trust's learning disability service (n = 295). The questionnaire sought: background details of respondents; numerical incidences and types of violence experienced over the previous 12 months; reporting mechanisms; reactions to and impact of violence on individuals and their work; support received. Vignettes provide a rich picture of the types of violent incidences and their impact. The findings show that 81% of staff in the learning disability service had experienced violence in the previous 12 months. Many had numerous experiences of violence. New and inexperienced staff are particularly vulnerable. Training and support systems are, on the whole, limited. Support received from colleagues is generally regarded as more helpful than that of line management. To explore good practice elsewhere, semi-structured interviews were held with individuals working with potentially violent clients in organizations other than the learning disability service. Suggestions are offered for putting in place human resource strategies to reduce the incidences of violence and provide appropriate post-incident support for staff on a continuing basis.
Article
Violence toward mental health staff has been receiving national attention in the face of diminishing resources to treat what appears to be an increasingly violent patient population. Assaults by psychiatric patients against mental health care providers are both a reality and a concern, as the effects of violence can be devastating to the victim. Some staff rationalize that violence is an occupational hazard and believe that they are equipped to cope with it. Despite these beliefs, these victims suffer from many of the same physical and psychological sequelae as victims of a natural disaster or street crime. This review of literature will examine several studies dealing with the precipitants of violence in the mental health setting, the patient populations more likely to become violent and the mental healthcare staff at the greatest risk of becoming their victims. It will also discuss possible methods of preventing such acts of violence and techniques for both staff and patients to cope with violent behavior.
Article
The literature on accidental and violetn minor injuries in hospitals is reviewed. From it hypotheses about the causes and correlates of such accidents are derived. These theories are tested on a 2-year sample of accidents in a 2,400-patient mental hospital, using standard multivariate statistical procedures. Age, psychiatric disability, and sex prove to be correlates of rates of injury. Social disorganization is shown to be the intervening variable in the common theory that crowding leads to violent injury.
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The article reports on a 1-year descriptive study of aggressive incidents and staff counteraggressive strategies within a child psychiatry inpatient unit. Ninety-nine child/adolescent patients produced a total of 887 reportable aggressive incidents during the 12-month study period. Seclusion, activity restriction, physical restraint, and administration of p.r.n. medication were studied in relation to patient aggression. Results of the study confirm the hypotheses that (1) much patient aggression within defined clinical contexts conforms to patterns of prediction directly related to person and environmental variables, and (2) the primary value of counteraggression strategies such as seclusion and restraint resides in the acute management of aggressive children and not in long-term therapeutic functions. The article offers some recommendations for new research in this general area as well as suggestions for clinical applications of these methods.
Article
Records of 116 violent incidents perpetrated by special care patients over a twelve-month period were retrospectively examined. There was a marked seasonal variation in the number of incidents. Incidents took place predominantly in the seclusion rooms and in communal areas having relatively high patient density. Patients admitted from the National Health Service following unmanageable violent behaviour were over-represented. A small number of patients were responsible for a high proportion of incidents. Implications for prevention are discussed.
Article
Violent incidents in psychiatric institutions have been the focus of much study over the past few decades. But there has been little work looking at similar incidents in child and adolescent units. The authors set out to examine whether some of the patterns observed in adult populations are true of adolescent groups. The Gardener Unit was considered appropriate in light of reports of a higher frequency of assaultative behaviour among younger clients and because of the nature of problems presented by clients needing a secure environment. All violent incidents are automatically recorded. The violent incident register was examined between 1 June 1991 and 1 June 1992 and the information cross-checked with case notes and nursing reports. Demographic details, etc. were obtained from case notes. The results indicated a slightly higher daily incident rate than adult studies. At least half of the population were involved in some form of violent episode over the 12-month period. The majority of incidents were minor in nature. Nursing staff were the most frequent targets, although females showed an excess of inwardly directed aggression (self harm). A prior history of violent behaviour did not serve as a realistic predictor of frequency of violent incidents in this study. With increasing concern regarding the care of this disturbed group of young people, it was felt important to look closely at the nature of and handling of violent incidents on this unit. A second paper will consider in detail how these incidents were dealt with.
Article
The study evaluated the effects of using the principles of total quality management (TQM) to reduce aggressive incidents in the dining rooms at a state forensic hospital. A ten-member, multidisciplinary team, which included a patient representative and a private-sector mentor, used the TQM FADE method (focus, analyze, develop, and execute) to address the problem. The team analyzed violent mealtime incidents, reviewed mealtime policies and procedures, and conducted a patient survey. Five recommendations were made: substitute plastic utensils for silverware, play music selected by the hospital's music therapists, allow patients at the highest privilege levels to leave the dining room after eating, open the main courtyard and gym during meals, and train food service workers in therapeutic communication. One year after implementation of the recommendations, aggressive incidents in the dining rooms were reduced by 40 percent, assaults using silverware were eliminated, and a total of 70 nursing staff hours a day were saved by eliminating silverware control procedures in the dining rooms. The milieu in the dining rooms has been improved by the addition of music and more flexible procedures. TQM techniques can be effectively applied in public-sector institutions to analyze and solve problems such as mealtime violence.
Article
For at least the last 10 years, control and restraint (C&R) has gained increased popularity amongst nurses as a safe, professional and legal means to manage violence in health care settings. However, during this period there has been an increased momentum to find non-aversive management strategies for people with learning disabilities and there has been frequent debate on the abolition of practices which do not achieve this. More recently, the main criticisms of C&R have been the professional and ethical objections that the techniques used inflict some degree of pain or discomfort to the client, and the fact that it remains a reactive strategy with no theoretical framework for professional practice. On this basis, alternatives should be sought which seek to address these issues. This paper outlines the development of natural therapeutic holding, an approach which is non-aversive and which provides a theoretical structure for professionals to base their practice on in order to develop clear therapeutic goals for the client. Initial findings within a small community residential service for people with learning disabilities indicate that natural therapeutic holding was a preferred method of intervention strategy by staff, proving as effective as C&R in the management of violent incidents, with interventions being much shorter in duration and non-aversive in nature.
Article
This article provides a review of current knowledge on the problem of violence to nurses by patients and relatives. In particular, the article discusses the extent of such violence in nursing generally and across different specialties.
Article
The aim of the study was to survey the degree and the extent of violence towards nursing staff by patients within a hospital environment. The information gathered will form a basis for future reference once the care packages are developed in the community. The study investigated the number of recorded incidents of aggression towards nursing staff by patients (n= 164) in an NHS Trust hospital for one year (October 1993–September 1994). The degree of recorded incidents of aggression was analysed using the Overt Aggression Scale. The results showed that the degree of aggression was mostly moderate to mild and occurred mostly in the Learning Disability Unit. Male staff were more involved in actual recorded incidents than expected in the given population. Health care assistants were more likely to be involved in aggressive incidents than any other grade of staff. There were significant findings in the time and location of the recorded aggressive incidents. The study, therefore, highlights the need to report and record incidents, the need for ongoing training, skilful management of resources and the recognition of environmental factors that can lead to patients' violence and aggression towards nursing staff.
Article
To identify patterns in critical incidents at an inpatient adolescent unit, to determine differences among patients who engage in critical incidents and those who do not, and to ascertain if there is an association between involvement in incidents and outcome of treatment. Retrospective review of all critical incidents reported at an adolescent unit over 30 months. Of 243 adolescents consecutively admitted, 100 (41%) were involved in critical incidents. Aggressive acts were more common in male adolescents, among patients with conduct or oppositional disorder and/or in those with specific learning disorders, and occurred throughout the day. Self-destructive events were more common in female adolescents and among patients with borderline personality disorder, and took place mainly in the evening. Adolescents involved in critical incidents tended to have longer admissions and had a worse outcome, irrespective of other factors. Critical incidents are common among hospitalized adolescents and result in a poorer outcome. Increased structure during the evenings, problem-solving and social skills programmes for patients, and specific training for staff regarding management and minimization of critical incidents should be provided.
Article
There are few examples in the literature of the application of functional analysis to psychiatric inpatient aggression. Structural assessment approaches have dominated. This paper introduces a system for classifying the functions of aggression in psychiatric inpatients that was applied to 502 aggressive behaviours exhibited by patients in a secure forensic psychiatric hospital. At least one function was identified for the majority of aggressive incidents; the most common functions pertaining to patients' responses to the restrictions and demands of the inpatient setting, to express anger or to punish others perceived as provocative, and to maintain status. There was little evidence suggesting that aggression was used to obtain tangible rewards, to reduce social isolation, or to simply observe the suffering of others. Differences in the function of aggressive behaviour were found across victim types. Results of this study have implications for the prediction and prevention of inpatient aggression and for the treatment of aggressive inpatients.
Article
The management of acutely disturbed people during periods of psychiatric crisis poses a particular challenge for mental health professionals. The challenge is to maintain safety while providing a safe and therapeutic environment. Non-pharmaceutical methods currently used to accomplish this include special observations, de-escalation, behavioural contracts and locking doors. To compare the effects of various strategies used to contain acutely disturbed people during periods of psychiatric crisis (excluding seclusion and restraint and the use of 'as prescribed medication). For the 2006 update of this review, we searched the Ovid interface of CINAHL, CENTRAL and The Schizophrenia Groups register, EMBASE, MEDLINE, PsycINFO. Relevant randomised controlled trials involving people hospitalised with serious mental illness, comparing any non-pharmacological interventions aimed at containing people who were at risk of harming themselves or others, (such as those approaches that change observation levels, lock wards, manage staff patient ratios, use de-escalation techniques or behavioural contracts). Trials would have been reliably quality assessed and data extracted. Relative risks (RR) and 95% confidence intervals (CI) would have been calculated with a random effects model. Where possible, numbers needed to treat and harm (NNT, NNH) would have been estimated. The initial 1999 search identified over 2000 reports and the update search of 2006, an additional 2808 reports. Of these, only six seemed to have the potential to be relevant, but once they were obtained it was clear they could not be included. None focused upon non-pharmacological methods for containment of violence or self harm in people with serious mental illness. Current non-pharmacological approaches to containment of disturbed or violent behaviour are not supported by evidence from controlled studies. Clinical practice is based on evidence that is not derived from trials and continued practice entirely outside of well designed, conducted and reported randomised studies is difficult to justify.