Managing Significant Violence and Aggression

• Research type

  Research Study

• Full title

  An exploration of the management of significant violence and aggression in high and medium secure forensic psychiatric hospitals in Scotland and Northern Ireland

• IRAS ID

  266611

• Contact name

  Helen Walker

• Contact email

  helen.walker6@nhs.scot

• Sponsor organisation

  The State Hospital

• Clinicaltrials.gov Identifier

  not available, not available

• Duration of Study in the UK

  1 years, 11 months, 30 days

• Research summary

  Research Summary

  The aim of this study is twofold; firstly to examine the frequency and management of significant violence and aggression, secondly to explore the views of people involved directly or indirectly, in high and medium secure services.

  Objectives:
  • To examine recording procedures and policy documents associated with the management of significant violence and aggression in medium and high secure forensic services.
  • To reflect on factors that influence the decision making process that lead to caring for and managing patients who exhibit significant violent and aggressive behaviour, from staff, patient and carer perspectives.

  Research questions
  Stage 1
  • Are the policies and procedures for managing significant violent and aggressive incidents adequate in high and medium secure services?
  • How frequently do significant violent and aggressive incidents occur in medium and high secure services?
  • Consider the background factors that make it more likely that an individual will require seclusion or other interventions to manage violence and aggressive incidents

  Stage 2
  • Are significant violent and aggressive incidents dealt with in a satisfactory manner?
  • What management strategies are used to deal with significant violent and aggressive incidents in medium and high secure settings?
  • What factors influence the decision-making process?

  Interviews and focus groups will be used to gather information from patients, carers and staff in relation to the management of serious violence and aggression. Policy documents and data collection systems will be accessed and reviewed to establish the frequency of serious violent and aggressive behavior.

  Summary of Results

  INTRODUCTION
  There are several strategies that can be adopted to manage incidents of violence and aggression; examples include de-escalation, administering emergency medication, physical restraint and seclusion (Pulsford et al., 2013). A variety of factors are likely to influence the techniques used by staff when met with violent incidents, however best practice focuses on reducing the use of restrictive interventions for violent behaviours (Jonikas et al., 2004). Thus, echoing the guidance set by the Mental Health (Care and Treatment) (Scotland) Act (2003) that patients should be cared for in the ‘least restrictive environment’ and adopting the use of seclusion is considered as a last resort. The literature reports the importance of the therapeutic staff-patient relationship during incidents of violence and aggression (O’dowd et al., 2022). Patients have reported similar views and use of restraint and seclusion as necessary for safety (Fletcher et al., 2021; Pulsford et al., 2013). However, the positive use of restraint and seclusion was only reported by patients who had not directly experienced it first-hand (Van Der Merwe et al., 2013a). Patients with experience of restrictive practices describe a negative experience, such as the dehumanising feelings of having clothes and belongings removed, feelings of loneliness and anger, and the fear of being secluded again in future (Van Der Merwe et al., 2013).
  Although there is a growing body of research about carers’ experiences and burdens generally (Kelly & Casey, 2015), the needs and experiences of those who support individuals within secure forensic hospital care has been under researched (Samson, 2019). Feedback through the Triangle of Care: A Guide to Best Practice Scotland (2019) suggests that carers feel largely left out and angry, despite being willing to connect with staff and to do what they can to help resolve a crisis or improve the health and care needs of the person they care for. Given the importance of the subject area, further exploration was warranted.

  METHOD
  Aim/Research Questions
  The aim of this study is twofold; firstly, to examine the frequency and management of significant violence and aggression, secondly, to explore the views of people involved directly or indirectly, in high, medium and Intensive Psychiatric Care Unit (IPCU) secure mental health hospitals.

  Stage 1
  Research questions:
  • Are the policies and procedures for managing significant violent and aggressive incidents adequate within the secure mental health hospitals?
  • What is the prevalence of significant violent and aggressive incidents that occur within the secure mental health hospitals? (i.e. how often does it occur)
  Stage 2
  • What management strategies are used to manage significant violent and aggressive incidents within the secure mental health hospitals?
  • Is the management of violence and aggression patient focused?
  • What factors influence the decision-making process?

  Sample
  The study was undertaken across one high and three medium secure hospitals in Scotland and Northern Ireland. In addition, to one further clinical setting within Scotland an IPCU hospital that adopts the use of seclusion.

  Methods
  A sequential mixed method approach was utilised. Data were gathered on the frequency of violence and aggression from each secure hospital. A review of policies and procedures from all clinical settings was undertaken and compared against guidance set out by the Mental Welfare Commission, Good Practice Guide (2021). Views of staff, patients and carer co-ordinators were explored to gather detailed information on managing significant violence and aggression. All views were analysed using thematic analysis.
  RESULTS
  Policy Review
  All five hospitals had a policy relating to the management of violence and aggression and two had a seclusion policy. All polices were analysed against guidance set out by the Mental Welfare Commission (2019; 2021). This was in order to determine if guidance was: clear and easily understood; least restrictive; focussed on prevention; included training/ risk assessment and management; identified recording procedures; incorporated impact/review with patient and communication with both patients and named persons.

  Interviews from patients, staff and carer co-ordinators Three major themes (in bold) and seven subordinate themes (in italics) were generated during the process of analysis: Illusion of Inclusion; Relationships and communication; Fear of Failure; Responsibility and Emotion; Stuck in the middle; Policy, Practise and Prevention.

  CONCLUSION
  Findings emphasise the need for positive communication between staff–patient and carer relationships, with consistency in clinical practice. Participants acknowledged that patient care was disrupted, the therapeutic relationship was tested and experience of trauma was evident during significant incidents of managing violence and aggression.
  This reinforces the need to maintain a therapeutic environment free of aggressive tension and threats of violence. The need to further understand more about the prevalence of restrictive practices within Scotland’s forensic estate and critically review practise, is a missed opportunity to benchmark, share good practice within a whole system approach.

  IMPROVEMENT PLAN
  A targeted service improvement strategy has been developed, which involves a collaboration between the Forensic Network via the Lead Forensic Nurse Forum, Senior Leaders and Practice Development teams/departments.

• REC name

  West of Scotland REC 3

• REC reference

  19/WS/0095

• Date of REC Opinion

  29 Aug 2019

• REC opinion

  Further Information Favourable Opinion