Violence prevention and management in acute psychiatric care: aspects of nursing practice

Aim: The general aim of this thesis was to explore and evaluate different aspects of nursing practice in relation to prediction, prevention and management of patient violence in acute psychiatric care. The specific aims were: to evaluate the short-term predictive capacity of the violence risk assessment instrument Brøset Violence Checklist (BVC) when used by nurses in a psychiatric intensive care unit (study I), to compare the occurrences of coercive interventions and violence-related staff injuries before and after a two-year nursing development and violence prevention intervention (study II), to describe aspects of the caring approaches used by nurses in acute psychiatric intensive care units (study III) and finally (in study IV) to test the hypothesis that staff training according to the ‘Bergen model’ has a significant positive influence on the violence prevention and management climate in psychiatric inpatient wards, as perceived by patients and staff. Methods: Both quantitative and qualitative methods were used. In study I, data from the BVC and the Staff Observation Aggression Scale were retrospectively collected from a psychiatric intensive care unit (PICU) and analysed in an extended Cox proportional hazards model. In study II, register-based rates of coercive interventions and violence-related staff injuries were retrospectively collected from the same unit as in study I, and subsequently analysed through Chi-square tests. In study III, qualitative data were collected from 19 individual interviews with nurses working on four PICUs in different parts of Sweden. The data analysis was guided by the interpretive description approach. In study IV, a 13 item questionnaire was developed (called the E13). Each item was related to the violence prevention and management climate on inpatient units. The E13 was distributed to patients and staff on 41 psychiatric wards before the staff had been trained according to the Bergen model and subsequently to patients and staff on 19 wards where the staff had been trained. Data analysis included factor analysis, Fisher’s exact test, Cronbach’s alpha and Mann-Whitney U-test. Findings: A positive scoring by the nurses on any of the six BVC items resulted in a six-fold increase in the risk for short-term severe violence on the PICU. A negative scoring on all items correctly predicted no risk for severe violence in 99% of all assessments (study I). In study II, an increase in the total rate of coercive interventions was found on the PICU one year after the intervention, while the rate of violence related staff injury remained unchanged. However, during the study period, an unplanned re-organisation of the PICU, including a substantial reduction of beds, meant that the PICU from then on could only admit the most acutely ill patients. In study III, interviews with nurses working on four different PICUs revealed two caring approaches which were metaphorically named the bulldozer and the ballet dancer. The bulldozer approach functioned as a shield of power that protected the ward from chaos, but at the same time involved the risk for engaging in uncaring actions. The ballet dancer approach functioned as a means of initiating relationships with patients and appeared strongly related to caring actions. In study IV, four items of the E13 questionnaire were rated significantly more positive by staff on trained wards. These four items concerned good rules on the ward, the ability of staff to stay calm when approaching aggressive patients, the staff’s interest in understanding why a patient is acting aggressively and the ability of staff to approach aggressive patients at an early stage. One item was rated significantly more positive by patients on trained wards which was the item relating to the interest of staff in understanding why a patient is aggressive. No item was rated more negatively on trained wards. Conclusions: Violence prevention and management in nursing practice involves a caring approach in all levels of prevention; in the everyday care as well as in coercive situations. It involves protection of the dignity of the patient and the nurse-patient relationship. The BVC has a good predictive capacity but should primarily be used to initiate early preventive interventions. In evaluation studies of violence prevention and management interventions, a mixed methods design should be considered, including the perspective of patients

Cow and calf together : a study of wound healing, pain behaviours and growth in milk breed calves housed with their mother

Frågeställningen i den här studien var om sårläkning och uppvisande av smärtrelaterade beteenden efter avhorning påverkas av sociala faktorer. Sammanlagt 9 försöks- och 13 kontrollkalvar avhornades när de var 2,5–6 veckor gamla. Försökskalvarna hölls med sin mamma, i grupp tillsammans med de andra försökskalvarna och deras mammor. Kontrollkalvarna hölls i ensamboxar. I samband med avhorning mättes och fotograferades alla kalvars avhorningssår och dessa följdes sedan upp med nya mätningar och foton en gång per vecka under 4 veckor. Kalvarna observerades även vid 2, 4, 6, 24 och 48 timmar efter avhorning, varvid smärtrelaterade beteenden registrerades. De smärtrelaterade beteenden som mättes var huvudskakningar och huvudgnuggningar. Kalvarnas dagliga tillväxt från 1 dag innan till 3 dagar efter avhorning noterades även med avsikt att undersöka om skillnad mellan försöks- och kontrollgruppen förelåg. Genomgång av litteratur på området visar att stimulans och social interaktion kan påverka sårläkning positivt. Andra studier har visat att ökad smärta i samband med avhorning på kalvar ger minskad tillväxt. I den här studien sågs skillnader i sårläkning mellan försöks- och kontrollkalvar (p < 0,001) och försökskalvarna läkte sina sår snabbare. Vid tidpunkterna 6 respektive 48 timmar efter avhorning fanns även skillnader i antal huvudskakningar (p < 0,001 resp. p = 0,007) och det observerades överlag ett ökat antal huvudgnuggningar i kontrollgruppen, även om ingen statistiskt säkerställd skillnad kunde fastställas. Ingen skillnad i tillväxt i samband med avhorningen kunde uppmätas mellan grupperna i den här studien.The aim of this study was to evaluate whether wound healing and pain related behaviours after dehorning is affected by social factors. In total 22 calves were studied during the time around dehorning, when they were 2.5–6 weeks old. They were given two treatments, cow and calf kept together (n = 9) in a group with other calf-mother pairs and calves kept in individual pens (n = 13). Immediately after dehorning, the wounds were measured which was followed up by new measurements once a week for 4 weeks, and the size of each wound was compared to the size it had directly after dehorning. Each time, photographies of each wound were also taken. At 2, 4, 6, 24 and 48 hours after dehorning, behavioural pain related responses were also recorded. The pain behaviours recorded were head shakes and head rubbing. Daily growth, from one day before to three days after dehorning, was also recorded to evaluate if the two treatments could affect growth differently. Previous studies have showed that stimulating factors and social interaction can affect wound healing in rodents in a positive way, and that increased pain associated with dehorning decreases daily growth. In this study, there was a difference in wound healing between the two treatment groups, and the calves kept together with their mothers had a faster wound healing (p < 0.001). There were also differences between the average number of head shakes that the two groups performed. Calves that had access to their mother performed less head shakes at 6 and 48 hours after dehorning (p < 0,001 and p = 0,007). Generally, there were also a larger number of head rubs among calves that were individually housed, but no statistical difference could be measured in this study. No differences in growth in connection with the dehorning could be measured between the groups

The ‘Field’ in the Age of Intervention: Power, Legitimacy, and Authority Versus the ‘Local’

This article highlights the semantic and socio-political meaning of the ‘field’ as it is used in both academic research and policy practices: as a geographic and material space related to forms of intervention in International Relations (IR), and not as a disciplinary space. We argue that the notion of the ‘field’ carries colonial baggage in terms of denoting ‘backwardness’ and conflictual practices, as well as legitimising the need for intervention by peacebuilding, statebuilding, and development actors located outside the field. We also show how academic practices have tended to create a semiotic frame in which the inhabitants of the research and intervention space are kept at a distance from the researcher, and discursively stripped of their agency. Along similar lines, policy-practice has reinforced the notion of the field as being in need of intervention, making it subject to external control. This article suggests that the agency of the inhabitants of the field has to be re-cognised and de-colonised so that political legitimacy can be recovered from ‘intervention’

Migration behaviour of the African bush elephant (Loxodonta africana) in the conservancy of Ol Pejeta

The group living African bush elephant is a migratory animal which can move up to 3 km/day during rainy season, and up to 6 km/day during dry season. Their home range can cover up to 12 800 square kilometers in habitats with poor food availability. Many home ranges of elephants are considerably larger than many national parks and conservancies in Africa. To reduce the risk of conflicts between wild animals and people it is often recommended that wildlife corridors are installed in these areas. This has been done in the Ol Pejeta Conservancy in Kenya. Different family groups show huge variation in migration behaviour. Some groups do not migrate at all, some migrate to the same place annually, and some are completely nomadic and are constantly on the move. Recent reports have shown that elephants don’t migrate equal distances as they used to, which could be a direct consequence of increased human activity in the elephant habitat. Since the 80’s the elephant population in Kenya has increased, and so has the human population which has gone from 8,6 million 1960 to over 43 million in 2012. This rapid increase in human population has resulted in activities that intrude more and more on wild animal habitat. 76 % of the Kenyan soil is dry and not fit for cultivation, which increases the pressure on the fertile soil. This has resulted in the fact that many protected areas now are partly or totally isolated, which has led to conflicts between humans and wildlife when animals raid crops. These conflicts often lead to considerable economic losses and damage to property, humans or animals. The aim of this study was to determine if migration occurs in the elephant population of the Ol Pejeta Conservancy. This was done by installing 10 motion cameras by the 3 openings in the conservancy. The purpose was also to discuss the cause for the migration, and if it might be influenced by external factors. The result shows that during 3 weeks the cameras photographed 69 elephant passages that included 232 animals. Out of these, 41 were made by single animals, probably almost all lone males. 37 of the passages were made during the dark hours. The conclusion of this study is that migration is present in the elephant population in the Ol Pejeta Conservancy. The main reason for this is probably is that the pictures were taken during an extremely dry period of time, which has led to a shortfall in food and suitable mates, and high levels of competition between family groups

A descriptive survey study of violence management and priorities among psychiatric staff in mental health services, across seventeen european countries

BACKGROUND: In mental health services what is commonplace across international frontiers is that to prevent aggressive patients from harming themselves, other patients or staff, coercive measures and foremost, violence management strategies are required. There is no agreement, recommendations or direction from the EU on which measures of coercion should be practiced across EU countries, and there is no overall one best practice approach. METHODS: The project was conceived through an expert group, the European Violence in Psychiatry Research Group (EViPRG). The study aimed to incorporate an EU and multidisciplinary response in the determination of violence management practices and related research and education priorities across 17 European countries. From the EVIPRG members, one member from each country agreed to act as the national project coordinator for their country. Given the international spread of respondents, an eDelphi survey approach was selected for the study design and data collection. A survey instrument was developed, agreed and validated through members of EVIPRG. RESULTS: The results included a total of 2809 respondents from 17 countries with 999 respondents who self-selected for round 2 eDelphi. The majority of respondents worked in acute psychiatry, 54% (n = 1511); outpatient departments, 10.5% (n = 295); and Forensic, 9.3% (n = 262). Other work areas of respondents include Rehabilitation, Primary Care and Emergency. It is of concern that 19.5% of respondents had not received training on violence management. The most commonly used interventions in the management of violent patients were physical restraint, seclusion and medications. The top priorities for education and research included: preventing violence; the influence of environment and staff on levels of violence; best practice in managing violence; risk assessment and the aetiology and triggers for violence and aggression. CONCLUSION: In many European countries there is an alarming lack of clarity on matters of procedure and policy pertaining to violence management in mental health services. Violence management practices in Europe appear to be fragmented with no identified ideological position or collaborative education and research. In Europe, language differences are a reality and may have contributed to insular thinking, however, it must not be seen as a barrier to sharing best practice

CAN REHABILITATION IN THE HOME SETTING REDUCE THE BURDEN OF CARE FOR THE NEXT-OF-KIN OF STROKE VICTIMS? 1

Can rehabilitation in the home setting reduce the burden of care for the next-of-kin of stroke victims?. Background: More evidence of the efficacy of caregiver interventions is needed. The aim of this study was to evaluate whether counselling in the home setting reduces the care giver burden. Methods: Thirtysix patients after stroke, median age 53 years, with a close family member, were selected for an evaluation of the burden of care and 35 participated. They were part of a randomized controlled trial, comparing rehabilitation in the home setting with outpatient rehabili tation. In the home setting, counselling about the stroke and its consequences was included. Assessments with the Care giver Burden scale were made at 3 weeks, 3 months and one year after discharge. Results: The burden of the 2 groups did not differ. After the intervention, there was a tendency to a lower burden for the home setting. The burden for the home setting was then unchanged from 3 weeks to 1 year, while outpatient rehabilitation showed a reduced burden over time. For the home setting, significant correlations to activity level were seen after the intervention. Conclusion: A positive effect of counselling was seen, as the home setting burden tends to be lower after the intervention, while outpatient rehabilitation seems to adjust with time. The results suggest that counselling reduces burden and the remaining burden is associated with the patient&apos;s ability. Journal of Rehabilitation Medicin

A replication study of the City nurse intervention: reducing conflict and containment on three acute psychiatric wards

Conflict and containment on acute inpatient psychiatric wards pose a threat to patient and staff safety, and it is desirable to minimize the frequency of these events. Research has indicated that certain staff attitudes and behaviours might serve to accomplish this, namely, positive appreciation, emotional regulation and effective structure. A previous test of an intervention based on these principles, on two wards, showed a good outcome. In this study, we tested the same intervention on three further wards. Two ‘City nurses’ were employed to work with three acute wards, assisting with the implementation of changes according to the working model of conflict and containment generation. Evaluation was via before-and-after measures, with parallel data collected from five control wards. While simple before-and-after analysis of the two experimental wards showed significant reductions in conflict and containment, when a comparison with controls was conducted, with control for patient occupancy and clustering of results by ward, no effect of the intervention was found. The results were therefore ambiguous, and neither confirm nor contradict the efficacy of the intervention. A further intervention study may need to be conducted with a larger sample size to achieve adequate statistical power