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

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

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

Models, frameworks and theories in the implementation of programs targeted to reduce formal coercion in mental health settings: a systematic review

Introduction: Implementation models, frameworks and theories (hereafter tools) provide researchers and clinicians with an approach to understand the processes and mechanisms for the successful implementation of healthcare innovations. Previous research in mental health settings has revealed, that the implementation of coercion reduction programs presents a number of challenges. However, there is a lack of systematized knowledge of whether the advantages of implementation science have been utilized in this field of research. This systematic review aims to gain a better understanding of which tools have been used by studies when implementing programs aiming to reduce formal coercion in mental health settings, and what implementation outcomes they have reported. Methods: A systematic search was conducted using PubMed, CINAHL, PsycINFO, Cochrane, Scopus, and Web of Science. A manual search was used to supplement database searches. Quality appraisal of included studies was undertaken using MMAT—Mixed Methods Appraisal Tool. A descriptive and narrative synthesis was formed based on extracted data. Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines were followed in this review. Results: We identified 5,295 references after duplicates were removed. Four additional references were found with a manual search. In total eight studies reported in nine papers were included in the review. Coercion reduction programs that were implemented included those that were holistic, and/or used professional judgement, staff training and sensory modulation interventions. Eight different implementation tools were identified from the included studies. None of them reported all eight implementation outcomes sought from the papers. The most frequently reported outcomes were acceptability (4/8 studies) and adaptation (3/8). With regards to implementation costs, no data were provided by any of the studies. The quality of the studies was assessed to be overall quite low. Discussion: Systematic implementation tools are seldom used when efforts are being made to embed interventions to reduce coercive measures in routine mental health care. More high-quality studies are needed in the research area that also involves perspectives of service users and carers. In addition, based on our review, it is unclear what the costs and resources are needed to implement complex interventions with the guidance of an implementation tool. Systematic review registration: [Prospero], identifier [CRD42021284959]

The impact of packaging design on consumers perception of the products price range : A visual content analysis of shampoo containers

Föreliggande studie syftar till att undersöka hur förpackningsdesignen kan komma att påverka konsumentens uppfattning av produktens prisklass. En visuell innehållsanalys genomfördes av ett femtiotal schampoprodukter, detta för att plocka ut olika karaktäristiska designelement för respektive prisklass. Utifrån resultatet skapades två generiska behållare för vardera prisklasser, dessa behållare testades sedan i en enkätundersökning. I enkäten fick deltagarna bedöma i vilken prisklass de ansåg de olika behållarna att tillhöra på en skala 1– 9, ordningen på hur behållarna slumpades och deltagarna hade ingen aning vilka prisklasser de tillhörde. Resultatet från den visuella innehållsanalysen stämde relativt bra överens med enkätundersökningen, där deltagarna ansåg att majoriteten av behållarna tillhörde den prisklass som generiska behållarna designats för efter den visuella innehållsanalysen. Behållare låg A fick 93 poäng, Låg B fick 112 poäng. Medel A fick 122 poäng och medel B 155 poäng. Till sist fick hög A 153 poäng och hög B 173 poäng. Behållare medel B som fick alltså mer poäng än hög A, vilket var det enda som inte stämde överens med det förväntade resultatet. Slutsatsen som kunde dras var att de olika prisklasserna bestod av olika designmanér, samt att utformning av de grafiska elementen varierar inom prisklasserna.The present study is aiming to examine how the packaging design can affect the consumer’s perception of the product’s price range. A visual content analysis was performed on fifty shampoo products, to find characteristic design elements for each price range. Two generic containers for each price range was produced out of the result from the analysis, those containers were later tested in a survey. In the survey the participants were asked to rate the generic containers in what price range they thought they were on a scale of 1–9, the order of the containers was randomized and the participants did not have any knowledge of the container’s price. The results of the visual content analysis were nearly consistent with the results from the survey, where the participants felt that the containers belonged to the price range they were given after the visual content analysis. Container low A got 93 points, low B got 112 points. Medium A got 122 points and medium B got 155 points. At last high A got 153 points and high B 173 points. Container medium B got higher points than high A, which was the only result that did not consist with the expected. The conclusion is that each price range do have various design manners, and that the configuration of design elements do vary among different price ranges

The impact of packaging design on consumers perception of the products price range : A visual content analysis of shampoo containers

Föreliggande studie syftar till att undersöka hur förpackningsdesignen kan komma att påverka konsumentens uppfattning av produktens prisklass. En visuell innehållsanalys genomfördes av ett femtiotal schampoprodukter, detta för att plocka ut olika karaktäristiska designelement för respektive prisklass. Utifrån resultatet skapades två generiska behållare för vardera prisklasser, dessa behållare testades sedan i en enkätundersökning. I enkäten fick deltagarna bedöma i vilken prisklass de ansåg de olika behållarna att tillhöra på en skala 1– 9, ordningen på hur behållarna slumpades och deltagarna hade ingen aning vilka prisklasser de tillhörde. Resultatet från den visuella innehållsanalysen stämde relativt bra överens med enkätundersökningen, där deltagarna ansåg att majoriteten av behållarna tillhörde den prisklass som generiska behållarna designats för efter den visuella innehållsanalysen. Behållare låg A fick 93 poäng, Låg B fick 112 poäng. Medel A fick 122 poäng och medel B 155 poäng. Till sist fick hög A 153 poäng och hög B 173 poäng. Behållare medel B som fick alltså mer poäng än hög A, vilket var det enda som inte stämde överens med det förväntade resultatet. Slutsatsen som kunde dras var att de olika prisklasserna bestod av olika designmanér, samt att utformning av de grafiska elementen varierar inom prisklasserna.The present study is aiming to examine how the packaging design can affect the consumer’s perception of the product’s price range. A visual content analysis was performed on fifty shampoo products, to find characteristic design elements for each price range. Two generic containers for each price range was produced out of the result from the analysis, those containers were later tested in a survey. In the survey the participants were asked to rate the generic containers in what price range they thought they were on a scale of 1–9, the order of the containers was randomized and the participants did not have any knowledge of the container’s price. The results of the visual content analysis were nearly consistent with the results from the survey, where the participants felt that the containers belonged to the price range they were given after the visual content analysis. Container low A got 93 points, low B got 112 points. Medium A got 122 points and medium B got 155 points. At last high A got 153 points and high B 173 points. Container medium B got higher points than high A, which was the only result that did not consist with the expected. The conclusion is that each price range do have various design manners, and that the configuration of design elements do vary among different price ranges

"Experience, reliability and availability" : A questionnaire study on pregnant women's information behaviours

The purpose of this thesis is to contribute knowledge about what pregnant people’s information behaviours look like. With this study, we want to find out how people who are currently pregnant seek and avoid information and how they experience information is being conveyed to them. Based on earlier research the study looks for these answers using a web survey and a qualitative and quantitative content analysis. The study uses McKenzie’s (2003a) model of information practices and Sweeny et al. (2010) research on the concept of information avoidance. Due to the lack of access to research in this area, this quantitative and qualitative study tries to extend the knowledge by examining information habits from fortycurrently pregnant individuals, from a library and information science perspective. We examined how the pregnant persons seek information, what information they are passively assigned and what information they actively avoid. The results in this study show that pregnant women have a great need for information. They actively seek information to get answers to questions related to pregnancy, childbirth, and life after childbirth. They value reliable, fact-checked sources and they want the information to be true and based on science. This also means that they avoid sources where they see a risk that the information is incorrect. They are also assigned information in numerous ways, such as receiving tips on where to find pregnancy-related information

"Experience, reliability and availability" : A questionnaire study on pregnant women's information behaviours

The purpose of this thesis is to contribute knowledge about what pregnant people’s information behaviours look like. With this study, we want to find out how people who are currently pregnant seek and avoid information and how they experience information is being conveyed to them. Based on earlier research the study looks for these answers using a web survey and a qualitative and quantitative content analysis. The study uses McKenzie’s (2003a) model of information practices and Sweeny et al. (2010) research on the concept of information avoidance. Due to the lack of access to research in this area, this quantitative and qualitative study tries to extend the knowledge by examining information habits from fortycurrently pregnant individuals, from a library and information science perspective. We examined how the pregnant persons seek information, what information they are passively assigned and what information they actively avoid. The results in this study show that pregnant women have a great need for information. They actively seek information to get answers to questions related to pregnancy, childbirth, and life after childbirth. They value reliable, fact-checked sources and they want the information to be true and based on science. This also means that they avoid sources where they see a risk that the information is incorrect. They are also assigned information in numerous ways, such as receiving tips on where to find pregnancy-related information