Forståelse av pasientaggresjon og forklaringer på nedgang i voldsrate ved Regional sikkerhetsavdeling, Sandviken sykehus

A reduced amount of violence in a regional high security psychiatric ward - what happened and how to describe main dimensions of patient aggression? This thesis is based on 17 years of clinical data and experience from a forensic high security psychiatric ward. While description of violence rate in general points to large cultural and historical variation and considerable diversity in expression, the literature on psychiatric inpatient violence rate is sparse and mainly treats aggression as a homogenous phenomenon. Firstly, the aim of the thesis is to describe changes in ward variables during a period of 18 years and to apply these in exploring plausible explanatory variables for the observed reduction in violence rate during the middle part of this period. Secondly, in order to gain a more comprehensive understanding of patient aggression we also tested a 3-factor model of motivations for violent behaviour in inpatients in a forensic high security unit. Firstly, using historical-documentary methods, we documented a change in regime during the observation period of 17 years, allowing increased patient autonomy. This co-occurred with changes in ward staff and quality of treatment methods. Staff with experience from this part of the 17-year period, were interviewed about their explanations of the decline in violence rate. They suggested several explanatory variables for this decrease, whereof some of them addressed contextual factors. These where then formally tested by visually comparing the development in each suggested variable with the development in inpatient violence. This approach falsified some of the suggested explanations. Among those not falsified, introduction of procedures of post-incident interviews and increased ratio of female staff were the most frequent mentioned. Secondly, a common feature of the suggestions was more individualized treatment of patients. Confirmatory factor analysis of data based on staff s evaluations of incidents supported the 3-factor model of patient aggression with factors for irritable, instrumental and defensive aggression. Irritable was the most prevalent type of aggression in this context, followed by instrumental and defensive. The findings indicate that transforming a restrictive ward regime into allowing more patient autonomy quality of treatment can co-occur with reduced inpatient violence, but the research design does not allow us to conclude about causal relationship. Other variables suggested by experience clinicians to be relevant explanatory factors for the reduced violence incidence are staff qualities, improved management of risk situations and violence, promoting staff-patient cooperation, and more individualized treatments. All these factors changed at the time of the reduced violence incidence, and can thus have caused the reduced incidence of violence

Personal recovery and its challenges in forensic mental health: systematic review and thematic synthesis of the qualitative literature

Background There has been a call for a framework to guide recovery-oriented practices in forensic mental health services. Aims This study aims to examine personal recovery and its challenges in forensic mental health settings in relation to the established framework for personal recovery in mental illness: connectedness, hope, identity, meaning and empowerment (CHIME). Method This study is an updated and expanded systematic review and thematic synthesis of the qualitative literature. A systematic search of six electronic databases (Web of Science, Medline, PsycINFO, CINAHL, EMBASE and SocIndex) was carried out in January 2019, using the terms [Recover*] AND [Forensic OR Secure] AND [Patient* OR Offend* OR Service User*]. Only studies that included service user's own perceptions and were published from 2014 onward were included in the review. Data were examined with thematic synthesis and subsequently analysed in relation to the CHIME framework. Results Twenty-one studies were included in the review. Findings suggest that some adjustments to the original CHIME framework are needed for it to be more relevant to forensic populations, and that an additional recovery process regarding feeling safe and being secure (safety and security) could be added to CHIME, providing the CHIME-Secure framework (CHIME-S). Specific challenges and barriers for forensic recovery were identified and found to represent the opposite of the recovery processes defined by CHIME (e.g. hopelessness). Conclusions We present the CHIME-S as a framework for the personal recovery processes of forensic mental health service users. The CHIME-S may guide the recovery-oriented work of forensic mental health services

Violence rate dropped during a shift to individualized patient-oriented care in a high security forensic psychiatric ward

Background - Contextual variables such as staff characteristics, treatment programs, assessment routines and administrative structures are found to influence patient violence rates in psychiatric forensic wards. The possible effects of current developments in treatment philosophy emphasizing patientsˈ perspective and treatment involvement upon violence rate have not yet been examined. The aim of this paper is to analyse associations between such developments and the occurrence of violent incidents among patients in a high security forensic psychiatric ward. Methods - During a 17-year period with stable ward conditions, incidents of violence were systematically collected together with diagnostic, risk assessment and demographic patient characteristics. Changes in care- and organizational related variables such as nursing staff characteristics, treatment and management routines were collected. Multilevel modelling was applied to estimate the relationship between these variables and changes in violent incidents. Results - A substantial decline in the occurrence of violent incidents paralleled with changes in the ward during the middle phase of the study period. Most of the changes, such as implementation of new treatment and care routines and an increased proportion of female staff and higher education levels, were significantly related to a decrease in the occurrence of violent incidents in the ward. Conclusions - Findings in this study suggest that an increase in individualized, patient-oriented care strategies, delivered by well-educated nursing staff with an equally balanced gender distribution contribute to a low level of violence