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Changes in the Occurrences of Coercive Interventions and Staff Injuries on a Psychiatric Intensive Care Unit
Changes in the Occurrences of Coercive Interventions and Staff Injuries on a Psychiatric Intensive Care Unit Anna Björkdahl, Markus Heilig, Tom Palmstierna, and Görel Hansebo The purpose of this study was to compare the occurrences of coercive interventions and violence-related staff injuries before and after a 2-year violence prevention intervention on a psychiatric intensive care unit. The intervention aimed to improve nursing care by addressing patient violence from multiple perspectives. During the study, the unit was reorganized toward a higher concentration of severely disturbed patients. The results showed an increased proportion of coercive interventions without a corresponding increase in staff injuries. Use of coercive interventions is discussed in relation to a safe environment for both patients and staff. n 2007 Elsevier Inc. All rights reserved.
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HE DEINSTITUTIONALIZATION of psychiatric care in Sweden, as in many other countries, has led to an extensive reduction in beds in psychiatric inpatient settings. In Stockholm, the number of beds has been reduced from 3,219 in 1991 to 559 in 2003 (SOS, 2003). As a consequence, only patients with very severe psychiatric conditions are admitted to inpatient settings—and often for only short lengths of stay (Delaney, 2006). To secure a safe and therapeutic environment on psychiatric units, researchers and clinicians have increasingly focused on understanding patient From the Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institute, Stockholm, Sweden; National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD, USA; Forensic Department and Research Center at Regional Secure Unit Brøset, St. Olav's Hospital, Norwegian University of Science and Technology, Trondheim, Norway; and Department of Health Care Sciences, Ersta Sköndal University College, Stockholm, Sweden. Address reprint requests to Anna Björkdahl, RMN, Stockholms Läns Sjukvårdsområde, Folkungagatan 44, Box 179 14, SE-118 95 Stockholm, Sweden. E-mail address: [email protected] n 2007 Elsevier Inc. All rights reserved. 0883-9417/1801-0005$30.00/0 doi: 10.1016/j.apnu.2007.06.007
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aggression and violence as well as the development of strategies for prevention and management. In this study, the effects of a 2-year violence prevention intervention on a specific psychiatric intensive care unit (PICU) were examined. During the study, the unit underwent a radical reduction in beds and could thereafter only admit patients during their most acute phase. The intervention included the introduction of primary nursing teams, risk prediction, early preventive nursing interventions, and guidelines for the use of restraint. Specifically, the occurrences of coercive interventions and violence-related staff injuries were compared before and after the intervention. BACKGROUND
Use of Coercive Interventions Coercive interventions are sometimes used to prevent aggressive patients from harming others or themselves. In Sweden, use of coercive interventions is regulated by law and must always be ordered by a physician. Coercive interventions include seclusion and restraint of a patient (i.e., forced injection and mechanical restraint; SFS, 1991). The use of seclusion and restraint can often be highly stressful events for patients, nurses, and physicians. Patients exposed to
Archives of Psychiatric Nursing, Vol. 21, No. 5 (October), 2007: pp 270–277
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these measures describe feelings of embarrassment, fear, powerlessness, and anger. In addition, many patients think that the interventions could have been avoided or at least carried out in a different manner (Bonner, Lowe, Rawcliffe, & Wellman, 2002; Haglund, von Knorring, & von Essen, 2003; Johnson, 1998; Olofsson & Jacobsson, 2001). For nurses and physicians, the use of seclusion and restraint often involves an ethical dilemma when they are forced to act against the patient's will (Marangos-Frost & Wells, 2000; Olofsson, Gilje, Jacobsson, & Norberg, 1998). Furthermore, research findings showed that the use of restraint can increase the risk for physical injury for both patients and staff and has in some cases been associated with deaths of patients (Paterson et al., 2003; The Joint Commission, 1998). Work-Related Violence Nurses in psychiatric care represent one of the professional groups most exposed to work-related violence (Arnetz, Arnetz, & Söderman, 1998; Swedish Work Environment Authority, 2003). This may contribute to a high frequency of sick leaves and even lead to conditions such as posttraumatic stress disorder (Needham, Abderhalden, Halfens, Fischer, & Dassen, 2005; Rippon, 2000). Moreover, it can result in a dysfunctional ward culture characterized by fear or toughness among the staff in their interaction with patients (Morrison, 1990; Morrison et al., 2002). Causes of Patient Violence The causes of violent patient behavior on psychiatric institutions are multifactorial (Duxbury, 2002). In a systematic literature review, Johnson (2004) identified four categories of factors related to violence and aggression on inpatient psychiatric units: patient-related variables; staff-related variables; unit-related variables; and interactional variables. According to Duxbury (2002) and IlkiwLavalle and Grenyer (2003), nurses often believe that a patient's mental illness is one of the major reasons behind violent behavior and express that the use of medication and coercive measures is crucial. Violence management training often includes physical techniques for self-defense, the use of seclusion and restraint, and the use of verbal de-escalation to ensure staff security and confidence (Farrell & Cubit, 2005). However, researchers suggest that ways in which staff manage patient aggression and violence may be inseparable from the management
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of basic communication, interaction, and relationships with the patients in everyday care (Duxbury, 2002; Lee et al., 2003). In several studies, patients described lack of constructive communication and interaction between nurses and patients as an essential factor related to patient violence (Duxbury & Whittington, 2005; Ilkiw-Lavalle & Grenyer, 2003). Furthermore, Koivisto, Janhonen, and Vaisanen (2004) found that patients on acute psychiatric wards emphasize the importance of security and structure in their everyday care, being protected from other patients' aggression, and being prevented from causing harm to others. Johnson (2004) argued that although there are many patient-related variables significantly associated with inpatient violence (e.g., diagnosis, sex, and history of aggression), these variables cannot be influenced by nursing interventions. Therefore, a focus on the interplay of factors, such as the staff– patient relationship, patient violence, the use of coercive interventions, and occurrence of staff injuries, is, from a nursing perspective, of major relevance. METHODS
Purpose and Design The purpose of this retrospective study was to compare the occurrences of coercive interventions and violence-related staff injuries before and after a 2-year violence prevention intervention. The study variables (i.e., the occurrences of seclusion, forced medication, mechanical restraint, and violencerelated staff injuries) were measured 1 year before and 1 year after the intervention. Setting Psychiatric intensive care units are specialized short-term units where most patients are involuntarily admitted and in an acutely disturbed phase of a serious mental disorder (Beer, Pereira, & Paton, 2001; Brown & Wellman, 1998). Patients often show externally or internally directed aggressive behavior, other unpredictable behaviors, or loss of self-control. Care and treatment are carried out from a multidisciplinary perspective with an emphasis on medication, risk assessment, violence management, close observation, and immediate response to critical situations (Beer et al., 2001; Crowhurst & Bowers, 2002). The study was conducted at a Swedish PICU undergoing structural reorganization, including fewer beds and higher levels of patient acuity.
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The PICU, located in a general urban hospital in Sweden, was part of a clinical psychiatric department with a catchment area of 260,000 people. The PICU included two wards with a total of 28 beds and approximately 500 admissions per year, of which 96% are involuntary. The bed occupancy rate was 94%, and the ward exit doors were locked at all times. Patients were mainly referred by the psychiatric emergency admission ward or by other wards at the psychiatric department. Admission was, regardless of psychiatric diagnosis, caused by severe emotional and behavioral problems, often in terms of aggression, violence, or self-destructive behavior. Most of the patients (54%) suffered from schizophrenia or other psychosis-related diagnoses, followed by affective disorders and personality disorders (according to the International Classification of Diseases, 10th Revision). Patients with alcohol or substance abuse problems as their primary diagnosis were not referred to the PICU. The patients' median length of stay was 12 days (q1–q3 = 5–28 days), a period that enabled almost 60% of the patients to be discharged from the unit directly to their homes and outpatient services without the need to pass through any of the general wards. Each ward was staffed with a manager, 25 nursing staff, a psychiatrist, an assistant physician, a psychologist, a social worker, and an occupational therapist. The nursing staff on each ward worked in three shifts and included 7 (28%) registered nurses (RNs) and 18 (72%) psychiatric nursing assistants (PNAs). The number of nurses per patient, night shift staff excluded, was 1.5. The staff consisted of a minimum of 1 RN and 3 PNAs on each shift, including at least 2 male staff. Staff reported to the ward managers that the situation in the wards was often chaotic with high levels of patient violence, staff frustration, and staff concern for how this jeopardized the quality of treatment and care. There had been 68 work-related staff injuries caused by patient violence reported during the last year. At the same time, the use of coercive interventions was relatively high, with 227 forced injections on 518 patient admissions (44%). Intervention To prevent violence and improve the quality of nursing care, the psychiatric department initiated a 2-year (2000–2002) intervention. The intervention included the components discussed in the following subsections.
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Nurse Consultant An experienced psychiatric nurse was recruited as a nurse consultant (NC; the first author) on a fulltime basis to lead the intervention in collaboration with the management and staff. The NC conducted ward observations and individual interviews with all members of the multidisciplinary team before and after the intervention. The initial interviews and observations gave a picture of a unit lacking ward structure in general but especially in relation to nursing care. Simultaneously, the nursing staff spent extensive time guarding and controlling the most disturbed patients and administering medical treatment. Organization of Nursing Care The nursing staff on each ward was divided into four teams with one RN, three PNAs, and three to four patients each. Inspired by the model of primary nursing, the RNs were named primary nurses and given full responsibility for the nursing care of the patients in their team for 24 hours a day (Tiedeman & Lookinland, 2004). The NC and the nurses came to an agreement on what the team's scope of nursing responsibility should be, and this was clearly defined (Table 1). Nursing Documentation and Care Planning The NC offered the nurses continuous training and supervision in nursing documentation based on a structured keyword documentation model called VIPS (Well-Being, Integrity, Prevention, and Safety; Björkdahl, 1999; Ehnfors, ThorellEkstrand, & Ehrenberg, 1991). Simultaneously, the nurses were introduced to nursing care plans that emphasized planned nursing interventions for the individual patient. Together with the nursing staff, the NC developed a standardized nursing care plan for acutely aggressive patients. It was based on Table 1. Responsibility of the Primary Nursing Team • Establish individual nursing care plans, including prescribed nursing interventions • Have a daily one-on-one supportive interaction with each patient • Assess risk for violence according to the BVC and initiate preventive interventions if indicated • Assist the patient in activities of daily life (e.g., hygiene, cleaning, and purchases) • Carry out medical orders and tests
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the nursing diagnosis “risk for violence directed toward others” (Carpenito, 1997) and stated common etiological factors, short-term goals, and 35 suggestions for preventive nursing interventions. These covered aspects of patient participation, information, support, general care, environment, observation, and coordination. Prediction of Violence The Bröset Violence Checklist (BVC) was introduced to identify high-risk patients (Almvik, 2000; Woods & Almvik, 2002). The BVC estimates a patient's level of risk for violence during the next 24 hours. In the checklist, six behavior items are noted as present or absent: confusion; irritability; boisterousness; verbal threats; physical threats; and attacks on objects. On the PICU, a nurse was assigned to assess the patients in the team once on each shift during the patients' stay. If more than two items were present, interventions to prevent a violent incident had to be initiated by the primary nursing team, typically guided by the standardized care plan. Guidelines for the Use of Restraint Guidelines for nursing aspects of forced injection (here defined as a patient being physically or mechanically restrained and injected against his or her will) and mechanical restraint (the patient's waist, wrists, and ankles are secured to a bed by belts, usually for ≤4 hours) were developed. The guidelines focused on maximum safety and security for patients and staff, with special attention to the patients' experience of being treated with human dignity (Beer et al., 2001; Marangos-Frost & Wells, 2000; Olofsson & Jacobsson, 2001). The final version included coordination, information to the patients, support to fellow patients, physical restraint, mechanical restraint, forced injection, and after-care support to the patients. Staff Training The NC was frequently present in the PICU. As staff training became an integrated part of the development in the work groups, the formal training was brief, with a 1-day introduction of the guidelines for coercive interventions for the whole multidisciplinary team, covering both theoretical aspects and basic practical training. The staff was also introduced to the standardized nursing
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care plan and the BVC in a 2-hour meeting. Written instructions for all new routines were kept at the nursing station and by the primary nursing teams. Reduction in Beds After 1 year, halfway into the intervention project, one of the PICU wards was closed. This was an effect of the harsh economic situation of the department and the ongoing trend of the Stockholm County Council to reduce the number of psychiatric inpatient beds. The remaining PICU ward consisted of 12 beds and only admitted patients with an explicit need for PICU treatment. This meant that the PICU staff would now care for patients during their very most acute phase and as soon as possible transfer them to the general wards. As a consequence, the management decided to change the staffing pattern into one that had an equal ratio of RNs and PNAs, with two primary nurses in each team. Furthermore, the previous policy of having at least two male nurses on every shift was changed into staffing based on the competence of each nurse regardless of sex. Data Collection The occurrence of coercive interventions was collected through reports made by the head psychiatrist of the PICU, which were forwarded every quarter of the year to the National Board of Health and Welfare as a statutory obligation. Data to assess the occurrence of violence-related staff injuries were obtained from the mandated occupational injury reports submitted by the staff victim, signed by the ward manager, and sent to the department management as well as the regional social insurance office. All reported injuries, physical or psychological, related to any form of patient aggression were included. Incidence rates were expressed as incidents per occupied bed day. The reports used to register coercive interventions did not contain any individual patient information. Similarly, descriptive data about the unit and staff as well as violence-related staff injuries were collected as aggregated frequencies without any possibility of identifying individual patients and staff. The intervention described was regarded as a regular part of the clinic's statutory obligation for continuous quality assurance (SOSFS, 2005) and was initiated by the head of the psychiatric department.
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Table 2. Comparative Data on the PICU for the Year Before and the Year After the Intervention Variable
1999
2003
Wards (n) Beds (n) Admissions (n) Involuntary (%) Bed occupancy (%) Patient length of stay in days [Mdn (q1–q3)] Patients Age [years, M (range)] Females (%) Main diagnosis (%) Schizophrenia Other psychosis Affective disorder Personality disorder Nursing staff (full-time equivalent, n) Daytime shift RNs Night shift RNs Daytime shift PNAs Night shift PNAs Staff:patient ratio *
2 28 518 96 94 12 (5–28)
1 12 336 91 80 7 (3–14)
41.9 (18–90) 50.5
41.1 (18–78) 47.7
31 23 27 9
36 27 25 5
12 2 30 6 1.5
11 2 12 8 1.9
* Night shift staff excluded.
Data Analysis Descriptive statistics were used to summarize the characteristics of the unit. Chi-squared tests were used to examine the differences between incidence rates before and those after the intervention. The statistical significance level was set at .05. Analyses were performed using the Statistica software (Version 7.1, StatSoft, Tulsa, OK, USA). RESULTS
An overview of descriptive data on the PICU for 1999 (year before the intervention) and 2003 (year after the intervention) is presented in Table 2. It shows that, as a result of the reduction in beds from 28 to 12, there was an expected changes towards a shorter length of stay. At the same time the bed occupancy rate decreased (from 94% to 80%). Staff:patient ratios increased from 1.5 to 1.9 and included a higher proportion of RNs. Furthermore, significant increases in coercive interventions as a total (P b .001) and specifically in the use of
mechanical restraint (P b .001) and seclusion (P = .003) were found 1 year after the intervention. The only coercive intervention that did not increase was the occurrence of forced injections, which showed no significant difference before and after the intervention (P = .218). We also found that the occurrence of violence-related staff injuries decreased from 0.007 to 0.004 per occupied bed day. This difference was not statistically significant, however (P = .112; Table 3). DISCUSSION
The PICU in this study had a reduction in its bed capacity from 28 to 12 beds while still serving the same catchment area and population. It also went from discharging most patients directly to their homes to observing a policy stating that patients should be transferred to the general wards as soon as possible (i.e., before they were in a dischargeable condition). Therefore, it is reasonable to assume that the bed reduction led to a concentration of more
Table 3. Incidents per Occupied Bed Day for the Year Before and the Year After the Intervention Variable
Seclusion Forced injection Mechanical restraint Total coercive interventions Staff injury
1999 [incidence rate (n)]
0.012 0.023 0.009 0.045 0.007
(113) (227) (94) (434) (68)
2003 [incidence rate (n)]
0.018 0.027 0.025 0.071 0.004
(65) (96) (88) (249) (16)
χ2
P
8.83 1.52 44.08 34.84 2.55
.003 .218 b.001 b.001 .110
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severely disturbed patients on the ward and that care and treatment would need to focus on the management of acute aggressive and violent patient behaviors. The significant increase in coercive measures, especially mechanical restraint, is not surprising under these circumstances. The unaltered ratio of forced injection is a finding that must be interpreted with caution as the definition of forced injection was changed by the National Board of Health and Welfare in 2000 as to always include a physical or mechanical restraint (SOSFS, 2000). In this study, the violence-related staff injuries did not increase. This finding is of special interest because the use of mechanical restraint, which did increase, is an intervention intended only for severely dangerous situations and always includes close physical contact with patients. The finding suggests that the intervention promoted an improved ability of the nurses to approach acute patient violence in a safer way. However, as the number of coercive interventions increased, there is a risk that the psychological safety of the violent patients could have been compromised (Johnson, 1998). In a review of the literature, Gerolamo (2006) found that physical restraint episodes are sensitive to the organization of nursing care on psychiatric wards. The connection is complex, however. Khadivi, Patel, Atkinson, and Levine (2004) observed that a nursing-based intervention that reduced the use of restraint and that of seclusion at the same time led to increased numbers of assaults on both patients and staff. Similarly, preliminary results from the City Nurse Project, aimed at reducing conflict and containment on acute psychiatric wards, showed a significant reduction in patient conflict behaviors (e.g., violence) but not in containment (e.g., restraint). The results indicate that a reduction in patient conflict behaviors does not automatically lead to lower levels of containment use (Bowers, Brennan, Flood, Lipang, & Oladapo, 2006; Flood et al., 2006). Interestingly, the City Nurse Project included components similar to the interventions in this study (e.g., a long duration, the role of an NC, a close involvement of staff, and a multidimensional approach to patient violence). A multidimensional approach has been recommended in research (Duxbury & Whittington, 2005; Nijman, à Campo, Ravelli, & Merckelbach, 1999) and was reflected by the combined introduction of structured nursing tools (e.g., the BVC based
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on patient behavior) and new routines to promote the relationship between patients and nurses in everyday care in our study. The finding of an increased proportion of coercive interventions without a corresponding increase in staff injuries could also have been affected by factors outside the intervention (e.g., the increase in the staff:patient ratio and the higher proportion of RNs). However, the impact of staffing levels and staff educational levels on patient violence is unclear (Ng, Kumar, Ranclaud, & Robinson, 2001; Owen, Tarantello, Jones, & Tennant, 1998). An increase in staff:patient ratios has been associated with unaltered amounts of violence but a reduction in staff injuries (Drinkwater & Gudjonsson, 1989; Palmstierna & Wistedt, 1995). At the same time, Williams and Myers (2001) showed that a higher proportion of licensed nurses increased the use of less restrictive interventions. This effect was not found in our study and may reflect the subsequently higher concentration of severely disturbed patients. Undoubtedly, the safety and protection of patients and staff on psychiatric wards involve a delicate clinical balance and a well-known ethical dilemma. The violent patient needs to be protected not only from hurting or intimidating other persons but also from experiencing possible humiliation, fright, and powerlessness by being the subject of coercive interventions. Quirk, Lelliott, and Seale (2005) found that patients on acute psychiatric admission wards often develop several ways to avoid assault and harassment from other patients. Consequently, the patients on the wards need to be protected from other patients' intimidating or violent behavior. Finally, the staff need to be protected from violent patient behavior causing unacceptable working conditions as well as physical and psychological damage. On PICUs, where one of the main indicators of admission is acute violent behavior and where patient violence is expected as an almost daily event, this dilemma is constantly present. In summary, although not conclusive, the results of this study suggest that a structured and multidimensional intervention aimed at improving acute psychiatric nursing care could have beneficial effects on staff safety, even in a changing ward organization resulting in a concentration of severely disturbed patients. However, high demands must be put on the expert competence of PICU nurses and
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organizations to recognize the complexity of what constitutes a safe ward environment for the violent patient, the other patients on the ward, and the staff. Future research should acknowledge and address this ethically complicated balance to support nurses in their efforts to reduce the occurrences of coercive interventions and staff injuries. REFERENCES Almvik, R. (2000). The Bröset Violence Checklist: Sensitivity, specificity and interrater reliability. Journal of Interpersonal Violence, 15, 1284–1296. Arnetz, J. E., Arnetz, B. B. & Söderman, E. (1998). Violence toward health care workers. Prevalence and incidence at a large, regional hospital in Sweden. AAOHN Journal: official journal of the American Association of Occupational Health Nurses, 46(3), 107–114. Beer, D., Pereira, S. & Paton, C. (2001). Psychiatric intensive care. London: Greenwich Medical Media Limited. Björkdahl, A. (1999). Psyk-VIPS (Swe). Lund: Studentlitteratur. Bonner, G., Lowe, T., Rawcliffe, D. & Wellman, N. (2002). Trauma for all: A pilot study of the subjective experience of physical restraint for mental health inpatients and staff in the UK. Journal of Psychiatric and Mental Health Nursing, 9(4), 465–473. Bowers, L., Brennan, G., Flood, C., Lipang, M. & Oladapo, P. (2006). Preliminary outcomes of a trial to reduce conflict and containment on acute psychiatric wards: City Nurses. Journal of Psychiatric and Mental Health Nursing, 13 (2), 165–172. Brown, K. & Wellman, N. (1998). Psychiatric intensive care: A developing specialty. Nursing Standard, 12(29), 45–47. Carpenito, L. J. (1997). Nursing diagnosis: Application to clinical practice. (7th ed.). Philadelphia: Lippincott. Crowhurst, N. & Bowers, L. (2002). Philosophy, care and treatment on the psychiatric intensive care unit: Themes, trends and future practice. Journal of Psychiatric and Mental Health Nursing, 9(6), 689–695. Delaney, K. R. (2006). Inpatient psychiatric treatment: Should we revive a shrinking system? Archives of Psychiatric Nursing, 20(5), 242–244. Drinkwater, J. & Gudjonsson, G. H. (1989). The nature of violence in psychiatric hospitals. In K. Howells & C. R. Hollin (Eds.), Clinical approaches to violence (pp. 287–307). New York: Wiley. Duxbury, J. (2002). An evaluation of staff and patient views of and strategies employed to manage inpatient aggression and violence on one mental health unit: A pluralistic design. Journal of Psychiatric and Mental Health Nursing, 9(3), 325–337. Duxbury, J. & Whittington, R. (2005). Causes and management of patient aggression and violence: Staff and patient perspectives. Journal of Advanced Nursing, 50(5), 469–478. Ehnfors, M., Thorell-Ekstrand, I. & Ehrenberg, A. (1991). Towards basic nursing information in patient records. Vard i Norden, 11(3–4), 12–31. Farrell, G. & Cubit, K. (2005). Nurses under threat: A comparison of content of 28 aggression management
programs. International Journal of Mental Health Nursing, 14(1), 44–53. Flood, C., Brennan, G., Bowers, L., Hamilton, B., Lipang, M. & Oladapo, P. (2006). Reflections on the process of change on acute psychiatric wards during the City Nurse Project. Journal of Psychiatric and Mental Health Nursing, 13(3), 260–268. Gerolamo, A. M. (2006). The conceptualization of physical restraint as a nursing-sensitive adverse outcome in acute care psychiatric treatment settings. Archives of Psychiatric Nursing, 20(4), 175–185. Haglund, K., von Knorring, L. & von Essen, L. (2003). Forced medication in psychiatric care: Patient experiences and nurse perceptions. Journal of Psychiatric and Mental Health Nursing, 10(1), 65–72. Ilkiw-Lavalle, O. & Grenyer, B. F. (2003). Differences between patient and staff perceptions of aggression in mental health units. Psychiatric Services, 54(3), 389–393. Johnson, M. E. (1998). Being restrained: A study of power and powerlessness. Issues in Mental Health Nursing, 19, 191–206. Johnson, M. E. (2004). Violence on inpatient psychiatric units: State of the science. Journal of American Psychiatric Nurses Association, 10(3), 113–121. Khadivi, A. N., Patel, R. C., Atkinson, A. R. & Levine, J. M. (2004). Association between seclusion and restraint and patient-related violence. Psychiatric Services, 55(11), 1311–1312. Koivisto, K., Janhonen, S. & Vaisanen, L. (2004). Patients' experiences of being helped in an inpatient setting. Journal of Psychiatric and Mental Health Nursing, 11(3), 268–275. Lee, S., Gray, R., Gournay, K., Wright, S., Parr, A. M. & Sayer, J. (2003). Views of nursing staff on the use of physical restraint. Journal of Psychiatric and Mental Health Nursing, 10(4), 425–430. Marangos-Frost, S. & Wells, D. (2000). Psychiatric nurses' thoughts and feelings about restraint use: A decision dilemma. Journal of Advanced Nursing, 31(2), 362–369. Morrison, E. F. (1990). The tradition of toughness: A study of nonprofessional nursing care in psychiatric settings. Image — the Journal of Nursing Scholarship, 22(1), 32–38. Morrison, E., Morman, G., Bonner, G., Taylor, C., Abraham, I. & Lathan, L. (2002). Reducing staff injuries and violence in a forensic psychiatric setting. Archives of Psychiatric Nursing, 16(3), 108–117. Needham, I., Abderhalden, C., Halfens, R. J., Fischer, J. E. & Dassen, T. (2005). Non-somatic effects of patient aggression on nurses: A systematic review. Journal of Advanced Nursing, 49(3), 283–296. Ng, B., Kumar, S., Ranclaud, M. & Robinson, E. (2001). Ward crowding and incidents of violence on an acute psychiatric inpatient unit. Psychiatric Services, 52(4), 521–525. Nijman, H., à Campo, J., Ravelli, D. & Merckelbach, H. (1999). A tentative model of aggression on inpatient psychiatric wards. Psychiatric Services, 50(6), 832–834. Olofsson, B., Gilje, F., Jacobsson, L. & Norberg, A. (1998). Nurses' narratives about using coercion in psychiatric care. Journal of Advanced Nursing, 28(1), 45–53. Olofsson, B. & Jacobsson, L. (2001). A plea for respect: Involuntarily hospitalized psychiatric patients' narratives
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about being subjected to coercion. Journal of Psychiatric and Mental Health Nursing, 8(4), 357–366. Owen, C., Tarantello, C., Jones, M. & Tennant, C. (1998). Violence and aggression in psychiatric units. Psychiatric Services, 49(11), 1452–1457. Palmstierna, T. & Wistedt, B. (1995). Changes in inpatient aggressive behaviour with changed ward organization. Acta Psychiatrica Scandinavica, 91(1), 32–35. Paterson, B., Bradley, P., Stark, C., Saddler, D., Leadbetter, D. & Allen, D. (2003). Deaths associated with restraint use in health and social care in the UK. The results of a preliminary survey. Journal of Psychiatric and Mental Health Nursing, 10(1), 3–15. Quirk, A., Lelliott, P. & Seale, C. (2005). Risk management by patients on psychiatric wards in London: An ethnographic study. Health, Risk and Society, 7(1), 85–91. Rippon, T. J. (2000). Aggression and violence in health care professions. Journal of Advanced Nursing, 31(2), 452–460. SFS. (1991). The Compulsory Psychiatric Care Act (1991:1128) (Swe). Stockholm: National Board of Health and Welfare. SOS. (2003). Investigation of the Åkeshov and Gamla Stan incidents and their possible relation to insufficient treatment within the psychiatric care and the social services (S2003/5291/HS) (Swe). Stockholm: National Board of Health and Welfare.
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SOSFS. (2000). The compulsory psychiatric care and forensic psychiatric care regulations and general advice (2000:12) (Swe). Stockholm: National Board of Health and Welfare. SOSFS. (2005). Code of statutes regulating the management of quality and patient safety in health care (2005:12) (Swe). Stockholm: National Board of Health and Welfare. Swedish Work Environment Authority. (2003). Violence and threats in the work environment, Korta sifferfakta 2 (Swe). Accessed 3-23-07 at: http://www.av.se/dokument/ statistik/sf/sf2003_02.pdf 2003. The Joint Commission. (1998). Preventing restraint deaths. Sentinel Event Alert, 8. Accessed 3-23-07 at: http://www. jointcommission.org/SentinelEvents/SentinelEventAlert/ sea_8.htm 1998. Tiedeman, M. E. & Lookinland, S. (2004). Traditional models of care delivery: What have we learned? Journal of Nursing Administration, 34(6), 291–297. Williams, J. E. & Myers, R. E. (2001). Relationship of less restrictive interventions with seclusion/restraints usage, average years of psychiatric experience, and staff mix. Journal of the American Psychiatric Nurses Association, 7(5), 139–144. Woods, P. & Almvik, R. (2002). The Bröset Violence Checklist (BVC). Acta Psychiatrica Scandinavica Supplementum (412), 103–105.
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HE DEINSTITUTIONALIZATION of psychiatric care in Sweden, as in many other countries, has led to an extensive reduction in beds in psychiatric inpatient settings. In Stockholm, the number of beds has been reduced from 3,219 in 1991 to 559 in 2003 (SOS, 2003). As a consequence, only patients with very severe psychiatric conditions are admitted to inpatient settings—and often for only short lengths of stay (Delaney, 2006). To secure a safe and therapeutic environment on psychiatric units, researchers and clinicians have increasingly focused on understanding patient From the Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institute, Stockholm, Sweden; National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD, USA; Forensic Department and Research Center at Regional Secure Unit Brøset, St. Olav's Hospital, Norwegian University of Science and Technology, Trondheim, Norway; and Department of Health Care Sciences, Ersta Sköndal University College, Stockholm, Sweden. Address reprint requests to Anna Björkdahl, RMN, Stockholms Läns Sjukvårdsområde, Folkungagatan 44, Box 179 14, SE-118 95 Stockholm, Sweden. E-mail address: [email protected] n 2007 Elsevier Inc. All rights reserved. 0883-9417/1801-0005$30.00/0 doi: 10.1016/j.apnu.2007.06.007
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aggression and violence as well as the development of strategies for prevention and management. In this study, the effects of a 2-year violence prevention intervention on a specific psychiatric intensive care unit (PICU) were examined. During the study, the unit underwent a radical reduction in beds and could thereafter only admit patients during their most acute phase. The intervention included the introduction of primary nursing teams, risk prediction, early preventive nursing interventions, and guidelines for the use of restraint. Specifically, the occurrences of coercive interventions and violence-related staff injuries were compared before and after the intervention. BACKGROUND
Use of Coercive Interventions Coercive interventions are sometimes used to prevent aggressive patients from harming others or themselves. In Sweden, use of coercive interventions is regulated by law and must always be ordered by a physician. Coercive interventions include seclusion and restraint of a patient (i.e., forced injection and mechanical restraint; SFS, 1991). The use of seclusion and restraint can often be highly stressful events for patients, nurses, and physicians. Patients exposed to
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these measures describe feelings of embarrassment, fear, powerlessness, and anger. In addition, many patients think that the interventions could have been avoided or at least carried out in a different manner (Bonner, Lowe, Rawcliffe, & Wellman, 2002; Haglund, von Knorring, & von Essen, 2003; Johnson, 1998; Olofsson & Jacobsson, 2001). For nurses and physicians, the use of seclusion and restraint often involves an ethical dilemma when they are forced to act against the patient's will (Marangos-Frost & Wells, 2000; Olofsson, Gilje, Jacobsson, & Norberg, 1998). Furthermore, research findings showed that the use of restraint can increase the risk for physical injury for both patients and staff and has in some cases been associated with deaths of patients (Paterson et al., 2003; The Joint Commission, 1998). Work-Related Violence Nurses in psychiatric care represent one of the professional groups most exposed to work-related violence (Arnetz, Arnetz, & Söderman, 1998; Swedish Work Environment Authority, 2003). This may contribute to a high frequency of sick leaves and even lead to conditions such as posttraumatic stress disorder (Needham, Abderhalden, Halfens, Fischer, & Dassen, 2005; Rippon, 2000). Moreover, it can result in a dysfunctional ward culture characterized by fear or toughness among the staff in their interaction with patients (Morrison, 1990; Morrison et al., 2002). Causes of Patient Violence The causes of violent patient behavior on psychiatric institutions are multifactorial (Duxbury, 2002). In a systematic literature review, Johnson (2004) identified four categories of factors related to violence and aggression on inpatient psychiatric units: patient-related variables; staff-related variables; unit-related variables; and interactional variables. According to Duxbury (2002) and IlkiwLavalle and Grenyer (2003), nurses often believe that a patient's mental illness is one of the major reasons behind violent behavior and express that the use of medication and coercive measures is crucial. Violence management training often includes physical techniques for self-defense, the use of seclusion and restraint, and the use of verbal de-escalation to ensure staff security and confidence (Farrell & Cubit, 2005). However, researchers suggest that ways in which staff manage patient aggression and violence may be inseparable from the management
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of basic communication, interaction, and relationships with the patients in everyday care (Duxbury, 2002; Lee et al., 2003). In several studies, patients described lack of constructive communication and interaction between nurses and patients as an essential factor related to patient violence (Duxbury & Whittington, 2005; Ilkiw-Lavalle & Grenyer, 2003). Furthermore, Koivisto, Janhonen, and Vaisanen (2004) found that patients on acute psychiatric wards emphasize the importance of security and structure in their everyday care, being protected from other patients' aggression, and being prevented from causing harm to others. Johnson (2004) argued that although there are many patient-related variables significantly associated with inpatient violence (e.g., diagnosis, sex, and history of aggression), these variables cannot be influenced by nursing interventions. Therefore, a focus on the interplay of factors, such as the staff– patient relationship, patient violence, the use of coercive interventions, and occurrence of staff injuries, is, from a nursing perspective, of major relevance. METHODS
Purpose and Design The purpose of this retrospective study was to compare the occurrences of coercive interventions and violence-related staff injuries before and after a 2-year violence prevention intervention. The study variables (i.e., the occurrences of seclusion, forced medication, mechanical restraint, and violencerelated staff injuries) were measured 1 year before and 1 year after the intervention. Setting Psychiatric intensive care units are specialized short-term units where most patients are involuntarily admitted and in an acutely disturbed phase of a serious mental disorder (Beer, Pereira, & Paton, 2001; Brown & Wellman, 1998). Patients often show externally or internally directed aggressive behavior, other unpredictable behaviors, or loss of self-control. Care and treatment are carried out from a multidisciplinary perspective with an emphasis on medication, risk assessment, violence management, close observation, and immediate response to critical situations (Beer et al., 2001; Crowhurst & Bowers, 2002). The study was conducted at a Swedish PICU undergoing structural reorganization, including fewer beds and higher levels of patient acuity.
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The PICU, located in a general urban hospital in Sweden, was part of a clinical psychiatric department with a catchment area of 260,000 people. The PICU included two wards with a total of 28 beds and approximately 500 admissions per year, of which 96% are involuntary. The bed occupancy rate was 94%, and the ward exit doors were locked at all times. Patients were mainly referred by the psychiatric emergency admission ward or by other wards at the psychiatric department. Admission was, regardless of psychiatric diagnosis, caused by severe emotional and behavioral problems, often in terms of aggression, violence, or self-destructive behavior. Most of the patients (54%) suffered from schizophrenia or other psychosis-related diagnoses, followed by affective disorders and personality disorders (according to the International Classification of Diseases, 10th Revision). Patients with alcohol or substance abuse problems as their primary diagnosis were not referred to the PICU. The patients' median length of stay was 12 days (q1–q3 = 5–28 days), a period that enabled almost 60% of the patients to be discharged from the unit directly to their homes and outpatient services without the need to pass through any of the general wards. Each ward was staffed with a manager, 25 nursing staff, a psychiatrist, an assistant physician, a psychologist, a social worker, and an occupational therapist. The nursing staff on each ward worked in three shifts and included 7 (28%) registered nurses (RNs) and 18 (72%) psychiatric nursing assistants (PNAs). The number of nurses per patient, night shift staff excluded, was 1.5. The staff consisted of a minimum of 1 RN and 3 PNAs on each shift, including at least 2 male staff. Staff reported to the ward managers that the situation in the wards was often chaotic with high levels of patient violence, staff frustration, and staff concern for how this jeopardized the quality of treatment and care. There had been 68 work-related staff injuries caused by patient violence reported during the last year. At the same time, the use of coercive interventions was relatively high, with 227 forced injections on 518 patient admissions (44%). Intervention To prevent violence and improve the quality of nursing care, the psychiatric department initiated a 2-year (2000–2002) intervention. The intervention included the components discussed in the following subsections.
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Nurse Consultant An experienced psychiatric nurse was recruited as a nurse consultant (NC; the first author) on a fulltime basis to lead the intervention in collaboration with the management and staff. The NC conducted ward observations and individual interviews with all members of the multidisciplinary team before and after the intervention. The initial interviews and observations gave a picture of a unit lacking ward structure in general but especially in relation to nursing care. Simultaneously, the nursing staff spent extensive time guarding and controlling the most disturbed patients and administering medical treatment. Organization of Nursing Care The nursing staff on each ward was divided into four teams with one RN, three PNAs, and three to four patients each. Inspired by the model of primary nursing, the RNs were named primary nurses and given full responsibility for the nursing care of the patients in their team for 24 hours a day (Tiedeman & Lookinland, 2004). The NC and the nurses came to an agreement on what the team's scope of nursing responsibility should be, and this was clearly defined (Table 1). Nursing Documentation and Care Planning The NC offered the nurses continuous training and supervision in nursing documentation based on a structured keyword documentation model called VIPS (Well-Being, Integrity, Prevention, and Safety; Björkdahl, 1999; Ehnfors, ThorellEkstrand, & Ehrenberg, 1991). Simultaneously, the nurses were introduced to nursing care plans that emphasized planned nursing interventions for the individual patient. Together with the nursing staff, the NC developed a standardized nursing care plan for acutely aggressive patients. It was based on Table 1. Responsibility of the Primary Nursing Team • Establish individual nursing care plans, including prescribed nursing interventions • Have a daily one-on-one supportive interaction with each patient • Assess risk for violence according to the BVC and initiate preventive interventions if indicated • Assist the patient in activities of daily life (e.g., hygiene, cleaning, and purchases) • Carry out medical orders and tests
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the nursing diagnosis “risk for violence directed toward others” (Carpenito, 1997) and stated common etiological factors, short-term goals, and 35 suggestions for preventive nursing interventions. These covered aspects of patient participation, information, support, general care, environment, observation, and coordination. Prediction of Violence The Bröset Violence Checklist (BVC) was introduced to identify high-risk patients (Almvik, 2000; Woods & Almvik, 2002). The BVC estimates a patient's level of risk for violence during the next 24 hours. In the checklist, six behavior items are noted as present or absent: confusion; irritability; boisterousness; verbal threats; physical threats; and attacks on objects. On the PICU, a nurse was assigned to assess the patients in the team once on each shift during the patients' stay. If more than two items were present, interventions to prevent a violent incident had to be initiated by the primary nursing team, typically guided by the standardized care plan. Guidelines for the Use of Restraint Guidelines for nursing aspects of forced injection (here defined as a patient being physically or mechanically restrained and injected against his or her will) and mechanical restraint (the patient's waist, wrists, and ankles are secured to a bed by belts, usually for ≤4 hours) were developed. The guidelines focused on maximum safety and security for patients and staff, with special attention to the patients' experience of being treated with human dignity (Beer et al., 2001; Marangos-Frost & Wells, 2000; Olofsson & Jacobsson, 2001). The final version included coordination, information to the patients, support to fellow patients, physical restraint, mechanical restraint, forced injection, and after-care support to the patients. Staff Training The NC was frequently present in the PICU. As staff training became an integrated part of the development in the work groups, the formal training was brief, with a 1-day introduction of the guidelines for coercive interventions for the whole multidisciplinary team, covering both theoretical aspects and basic practical training. The staff was also introduced to the standardized nursing
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care plan and the BVC in a 2-hour meeting. Written instructions for all new routines were kept at the nursing station and by the primary nursing teams. Reduction in Beds After 1 year, halfway into the intervention project, one of the PICU wards was closed. This was an effect of the harsh economic situation of the department and the ongoing trend of the Stockholm County Council to reduce the number of psychiatric inpatient beds. The remaining PICU ward consisted of 12 beds and only admitted patients with an explicit need for PICU treatment. This meant that the PICU staff would now care for patients during their very most acute phase and as soon as possible transfer them to the general wards. As a consequence, the management decided to change the staffing pattern into one that had an equal ratio of RNs and PNAs, with two primary nurses in each team. Furthermore, the previous policy of having at least two male nurses on every shift was changed into staffing based on the competence of each nurse regardless of sex. Data Collection The occurrence of coercive interventions was collected through reports made by the head psychiatrist of the PICU, which were forwarded every quarter of the year to the National Board of Health and Welfare as a statutory obligation. Data to assess the occurrence of violence-related staff injuries were obtained from the mandated occupational injury reports submitted by the staff victim, signed by the ward manager, and sent to the department management as well as the regional social insurance office. All reported injuries, physical or psychological, related to any form of patient aggression were included. Incidence rates were expressed as incidents per occupied bed day. The reports used to register coercive interventions did not contain any individual patient information. Similarly, descriptive data about the unit and staff as well as violence-related staff injuries were collected as aggregated frequencies without any possibility of identifying individual patients and staff. The intervention described was regarded as a regular part of the clinic's statutory obligation for continuous quality assurance (SOSFS, 2005) and was initiated by the head of the psychiatric department.
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Table 2. Comparative Data on the PICU for the Year Before and the Year After the Intervention Variable
1999
2003
Wards (n) Beds (n) Admissions (n) Involuntary (%) Bed occupancy (%) Patient length of stay in days [Mdn (q1–q3)] Patients Age [years, M (range)] Females (%) Main diagnosis (%) Schizophrenia Other psychosis Affective disorder Personality disorder Nursing staff (full-time equivalent, n) Daytime shift RNs Night shift RNs Daytime shift PNAs Night shift PNAs Staff:patient ratio *
2 28 518 96 94 12 (5–28)
1 12 336 91 80 7 (3–14)
41.9 (18–90) 50.5
41.1 (18–78) 47.7
31 23 27 9
36 27 25 5
12 2 30 6 1.5
11 2 12 8 1.9
* Night shift staff excluded.
Data Analysis Descriptive statistics were used to summarize the characteristics of the unit. Chi-squared tests were used to examine the differences between incidence rates before and those after the intervention. The statistical significance level was set at .05. Analyses were performed using the Statistica software (Version 7.1, StatSoft, Tulsa, OK, USA). RESULTS
An overview of descriptive data on the PICU for 1999 (year before the intervention) and 2003 (year after the intervention) is presented in Table 2. It shows that, as a result of the reduction in beds from 28 to 12, there was an expected changes towards a shorter length of stay. At the same time the bed occupancy rate decreased (from 94% to 80%). Staff:patient ratios increased from 1.5 to 1.9 and included a higher proportion of RNs. Furthermore, significant increases in coercive interventions as a total (P b .001) and specifically in the use of
mechanical restraint (P b .001) and seclusion (P = .003) were found 1 year after the intervention. The only coercive intervention that did not increase was the occurrence of forced injections, which showed no significant difference before and after the intervention (P = .218). We also found that the occurrence of violence-related staff injuries decreased from 0.007 to 0.004 per occupied bed day. This difference was not statistically significant, however (P = .112; Table 3). DISCUSSION
The PICU in this study had a reduction in its bed capacity from 28 to 12 beds while still serving the same catchment area and population. It also went from discharging most patients directly to their homes to observing a policy stating that patients should be transferred to the general wards as soon as possible (i.e., before they were in a dischargeable condition). Therefore, it is reasonable to assume that the bed reduction led to a concentration of more
Table 3. Incidents per Occupied Bed Day for the Year Before and the Year After the Intervention Variable
Seclusion Forced injection Mechanical restraint Total coercive interventions Staff injury
1999 [incidence rate (n)]
0.012 0.023 0.009 0.045 0.007
(113) (227) (94) (434) (68)
2003 [incidence rate (n)]
0.018 0.027 0.025 0.071 0.004
(65) (96) (88) (249) (16)
χ2
P
8.83 1.52 44.08 34.84 2.55
.003 .218 b.001 b.001 .110
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severely disturbed patients on the ward and that care and treatment would need to focus on the management of acute aggressive and violent patient behaviors. The significant increase in coercive measures, especially mechanical restraint, is not surprising under these circumstances. The unaltered ratio of forced injection is a finding that must be interpreted with caution as the definition of forced injection was changed by the National Board of Health and Welfare in 2000 as to always include a physical or mechanical restraint (SOSFS, 2000). In this study, the violence-related staff injuries did not increase. This finding is of special interest because the use of mechanical restraint, which did increase, is an intervention intended only for severely dangerous situations and always includes close physical contact with patients. The finding suggests that the intervention promoted an improved ability of the nurses to approach acute patient violence in a safer way. However, as the number of coercive interventions increased, there is a risk that the psychological safety of the violent patients could have been compromised (Johnson, 1998). In a review of the literature, Gerolamo (2006) found that physical restraint episodes are sensitive to the organization of nursing care on psychiatric wards. The connection is complex, however. Khadivi, Patel, Atkinson, and Levine (2004) observed that a nursing-based intervention that reduced the use of restraint and that of seclusion at the same time led to increased numbers of assaults on both patients and staff. Similarly, preliminary results from the City Nurse Project, aimed at reducing conflict and containment on acute psychiatric wards, showed a significant reduction in patient conflict behaviors (e.g., violence) but not in containment (e.g., restraint). The results indicate that a reduction in patient conflict behaviors does not automatically lead to lower levels of containment use (Bowers, Brennan, Flood, Lipang, & Oladapo, 2006; Flood et al., 2006). Interestingly, the City Nurse Project included components similar to the interventions in this study (e.g., a long duration, the role of an NC, a close involvement of staff, and a multidimensional approach to patient violence). A multidimensional approach has been recommended in research (Duxbury & Whittington, 2005; Nijman, à Campo, Ravelli, & Merckelbach, 1999) and was reflected by the combined introduction of structured nursing tools (e.g., the BVC based
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on patient behavior) and new routines to promote the relationship between patients and nurses in everyday care in our study. The finding of an increased proportion of coercive interventions without a corresponding increase in staff injuries could also have been affected by factors outside the intervention (e.g., the increase in the staff:patient ratio and the higher proportion of RNs). However, the impact of staffing levels and staff educational levels on patient violence is unclear (Ng, Kumar, Ranclaud, & Robinson, 2001; Owen, Tarantello, Jones, & Tennant, 1998). An increase in staff:patient ratios has been associated with unaltered amounts of violence but a reduction in staff injuries (Drinkwater & Gudjonsson, 1989; Palmstierna & Wistedt, 1995). At the same time, Williams and Myers (2001) showed that a higher proportion of licensed nurses increased the use of less restrictive interventions. This effect was not found in our study and may reflect the subsequently higher concentration of severely disturbed patients. Undoubtedly, the safety and protection of patients and staff on psychiatric wards involve a delicate clinical balance and a well-known ethical dilemma. The violent patient needs to be protected not only from hurting or intimidating other persons but also from experiencing possible humiliation, fright, and powerlessness by being the subject of coercive interventions. Quirk, Lelliott, and Seale (2005) found that patients on acute psychiatric admission wards often develop several ways to avoid assault and harassment from other patients. Consequently, the patients on the wards need to be protected from other patients' intimidating or violent behavior. Finally, the staff need to be protected from violent patient behavior causing unacceptable working conditions as well as physical and psychological damage. On PICUs, where one of the main indicators of admission is acute violent behavior and where patient violence is expected as an almost daily event, this dilemma is constantly present. In summary, although not conclusive, the results of this study suggest that a structured and multidimensional intervention aimed at improving acute psychiatric nursing care could have beneficial effects on staff safety, even in a changing ward organization resulting in a concentration of severely disturbed patients. However, high demands must be put on the expert competence of PICU nurses and
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organizations to recognize the complexity of what constitutes a safe ward environment for the violent patient, the other patients on the ward, and the staff. Future research should acknowledge and address this ethically complicated balance to support nurses in their efforts to reduce the occurrences of coercive interventions and staff injuries. REFERENCES Almvik, R. (2000). The Bröset Violence Checklist: Sensitivity, specificity and interrater reliability. Journal of Interpersonal Violence, 15, 1284–1296. Arnetz, J. E., Arnetz, B. B. & Söderman, E. (1998). Violence toward health care workers. Prevalence and incidence at a large, regional hospital in Sweden. AAOHN Journal: official journal of the American Association of Occupational Health Nurses, 46(3), 107–114. Beer, D., Pereira, S. & Paton, C. (2001). Psychiatric intensive care. London: Greenwich Medical Media Limited. Björkdahl, A. (1999). Psyk-VIPS (Swe). Lund: Studentlitteratur. Bonner, G., Lowe, T., Rawcliffe, D. & Wellman, N. (2002). Trauma for all: A pilot study of the subjective experience of physical restraint for mental health inpatients and staff in the UK. Journal of Psychiatric and Mental Health Nursing, 9(4), 465–473. Bowers, L., Brennan, G., Flood, C., Lipang, M. & Oladapo, P. (2006). Preliminary outcomes of a trial to reduce conflict and containment on acute psychiatric wards: City Nurses. Journal of Psychiatric and Mental Health Nursing, 13 (2), 165–172. Brown, K. & Wellman, N. (1998). Psychiatric intensive care: A developing specialty. Nursing Standard, 12(29), 45–47. Carpenito, L. J. (1997). Nursing diagnosis: Application to clinical practice. (7th ed.). Philadelphia: Lippincott. Crowhurst, N. & Bowers, L. (2002). Philosophy, care and treatment on the psychiatric intensive care unit: Themes, trends and future practice. Journal of Psychiatric and Mental Health Nursing, 9(6), 689–695. Delaney, K. R. (2006). Inpatient psychiatric treatment: Should we revive a shrinking system? Archives of Psychiatric Nursing, 20(5), 242–244. Drinkwater, J. & Gudjonsson, G. H. (1989). The nature of violence in psychiatric hospitals. In K. Howells & C. R. Hollin (Eds.), Clinical approaches to violence (pp. 287–307). New York: Wiley. Duxbury, J. (2002). An evaluation of staff and patient views of and strategies employed to manage inpatient aggression and violence on one mental health unit: A pluralistic design. Journal of Psychiatric and Mental Health Nursing, 9(3), 325–337. Duxbury, J. & Whittington, R. (2005). Causes and management of patient aggression and violence: Staff and patient perspectives. Journal of Advanced Nursing, 50(5), 469–478. Ehnfors, M., Thorell-Ekstrand, I. & Ehrenberg, A. (1991). Towards basic nursing information in patient records. Vard i Norden, 11(3–4), 12–31. Farrell, G. & Cubit, K. (2005). Nurses under threat: A comparison of content of 28 aggression management
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SOSFS. (2000). The compulsory psychiatric care and forensic psychiatric care regulations and general advice (2000:12) (Swe). Stockholm: National Board of Health and Welfare. SOSFS. (2005). Code of statutes regulating the management of quality and patient safety in health care (2005:12) (Swe). Stockholm: National Board of Health and Welfare. Swedish Work Environment Authority. (2003). Violence and threats in the work environment, Korta sifferfakta 2 (Swe). Accessed 3-23-07 at: http://www.av.se/dokument/ statistik/sf/sf2003_02.pdf 2003. The Joint Commission. (1998). Preventing restraint deaths. Sentinel Event Alert, 8. Accessed 3-23-07 at: http://www. jointcommission.org/SentinelEvents/SentinelEventAlert/ sea_8.htm 1998. Tiedeman, M. E. & Lookinland, S. (2004). Traditional models of care delivery: What have we learned? Journal of Nursing Administration, 34(6), 291–297. Williams, J. E. & Myers, R. E. (2001). Relationship of less restrictive interventions with seclusion/restraints usage, average years of psychiatric experience, and staff mix. Journal of the American Psychiatric Nurses Association, 7(5), 139–144. Woods, P. & Almvik, R. (2002). The Bröset Violence Checklist (BVC). Acta Psychiatrica Scandinavica Supplementum (412), 103–105.