Evidence-based violence risk assessment in psychiatric inpatient care: an implementation study

The aim of this study was to promote evidence-based violence risk assessment in inpatient psychiatric care. The study was an implementation study with three phases utilizing a mixed-method approach. The Ottawa Model of Research Use was used as a theoretical framework. The setting was three closed adults’ psychiatric wards and two associations for families of mental health patients. The violence risk assessment intervention implemented was the Dynamic Appraisal of Situational Aggression. First, assessment of key elements for implementation was explored from the perspectives of nursing staff, relatives of mental health patients, and the practice environment. In addition, the intervention was specified. Second, implementation was monitored on the wards: barriers and facilitators for the implementation, knowledge transfer strategies, adaptation and use of the intervention were explored. Third, evaluation of outcomes of the intervention implemented was done from perspectives of nursing staff and mental health inpatients. The feasibility of the intervention was explored. Assessment of key elements revealed the views of nursing staffs and relatives of mental health patients on the complexity of violent events in psychiatric care and identified common needs for the development of violence prevention and management. Monitoring the implementation yielded knowledge about intervention implementation in the clinical practice setting and its challenges. Evaluation of implementation outcomes revealed mixed perceptions of violence risk assessment intervention and the feasibility criteria set were not fully met. This dissertation provides new insights which can be utilized when implementing novel methods to prevent and manage patent violence in more user-centered manners. On basis of the study results, patient involvement in short-term risk assessment can be seen as a new, promising working method in psychiatric inpatient care. Thus, to confirm this finding, more research is needed.Näyttöön perustuva väkivallan riskinarvointi psykiatrisessa sairaalahoidossa: implementointi-tutkimus Tutkimuksen tavoitteena oli edistää näyttöön perustuvaa väkivallan riskinarviointia psykiatrisessa sairaalahoidossa. Tutkimus toteutettiin implementointitutkimuksena hyödyntäen monimenetelmällisyyttä ja se jakautui kolmeen vaiheeseen Ottawa Model of Research Use viitekehyksen mukaisesti. Tutkimusympäristönä olivat kolme suljettua aikuispsykiatrista osastoa ja kaksi mielenterveysomaisten järjestöä. Tutkimuksessa käytäntöön viety väkivallan riskinarviointimenetelmä oli Dynamic Appraisal of Situational Aggression. Ensimmäisessä vaiheessa arvioitiin hoitohenkilökunnan, mielenterveysomaisten ja käytännön työympäristön näkökulmasta tärkeimpiä tekijöitä uuden menetelmän käytäntöön viemisen suhteen. Käytäntöön vietävä menetelmä tarkennettiin. Toisessa vaiheessa intervention käytäntöön viemistä seurattiin osastoilla: Käytäntöön viemistä estävät ja edistävät tekijät tunnistettiin. Strategiat menetelmän käytäntöön viemiseksi valittiin. Menetelmän käyttöönottoa seurattiin. Kolmannessa vaiheessa hoitohenkilökunta ja potilaat arvioivat käytäntöön viedyn menetelmän, sekä menetelmän käyttökelpoisuutta tutkittiin. Tutkimuksen tulosten mukaan uuden menetelmän käytäntöön viemisen tärkeimpinä huomioitavina tekijöitä olivat hoitajien ja mielenterveysomaisten näkökulmista väkivaltatilanteiden kompleksisuus psykiatrisessa hoidossa. Yhteisiä tarpeita väkivallan ennaltaehkäisemisen ja hallitsemisen kehittämiseksi löydettiin. Tulokset toivat tietoa menetelmien käytäntöön viemisen menetelmistä käytännön työympäristöissä ja siihen liittyvistä haasteista. Näkemykset käytäntöön viedystä väkivallan riskinarviointimenetelmästä olivat ristiriitaiset eivätkä asetetut kriteerit menetelmän käyttökelpoisuudesta täyttyneet täysin. Tämä väitöskirja tuottaa uutta tietoa, jota voidaan hyödyntää vietäessä käytäntöön uusia käyttäjälähtöisiä menetelmiä potilasväkivallan ennaltaehkäisemiseksi ja hallitsemiseksi. Potilaiden mukaanottoa väkivallan lyhyen aikavälin riskinarviointiin voidaan pitää tulosten perusteella uutena, lupaavana lähestymistapana psykiatrisessa sairaalahoidossa. Lisätutkimusta tarvitaan kuitenkin havainnon vahvistamiseksi.Siirretty Doriast

Vanhemmuusohjelmien käytettävyys haavoittuvassa asemassa olevien vanhempien näkökulmasta - Integratiivinen kirjallisuuskatsaus

Integratiivisen kirjallisuuskatsauksen tarkoituksena oli kuvata lasten mielenterveys- ja käytösongelmien ennaltaehkäisyyn ja hoitoon tarkoitettujen vanhemmuusohjelmien käytettävyyttä haavoittuvassa asemassa olevien vanhempien näkökulmasta. Tavoitteena oli tuottaa kuvaus vanhemmuusohjelmista sekä lisätä tietoa niiden saavutettavuutta edistävistä ja estävistä tekijöistä. Systemaattinen haku tehtiin PubMed/Medline, CINAHL, PsychINFO, Cochrane Library ja ERIC-tietokantoihin. Tiedonhaku rajattiin koskemaan interventiotutkimuksia. Aineisto analysoitiin deduktiivisesti käytettävyyttä kuvaavien osa-alueiden (hyväksyttävyys, tarve, implementointi, käytännöllisyys, adaptiivisuus, integrointi, siirrettävyys, vaikuttavuuden testaus) mukaisesti sekä laatimalla kuvaus vanhemmuusohjelmista TIDieR-tarkistuslistan mukaisesti. Katsaukseen valittiin mukaan 13 tutkimusta, jotka käsittelivät viittä eri vanhemmuusohjelmaa. Osallistumista edisti muun muassa käytännön järjestelyissä tukeminen, vanhemmuusohjelman maksuttomuus sekä palvelun sopivuus perheen tarpeisiin. Osallistumista puolestaan esti esimerkiksi muutokset perheen taloudellisessa tilanteessa sekä aikatauluongelmat. Kaikilla vanhemmuusohjelmilla oli lyhytaikaista vaikutusta lasten käytöshäiriöoireisiin. Ohjelmien käytön havaittiin vahvistavan vanhemmuustaitoja ja vähentävän vanhempien kuormitusta. Johtopäätöksenä voidaan todeta, että haavoittuvassa asemassa olevien vanhempien vanhemmuusohjelmien käytettävyyttä lisää oikea-aikaisesti tarjottu palvelu, palvelun osuvuus lapsen ja perheiden tarpeisiin, osallistumisen tukeminen sekä palvelun joustavuus

Quality of mental health services and rights of people receiving treatment in inpatient services in Finland: a cross-sectional observational survey with the WHO QualityRights Tool Kit

Background: This article aims to review the quality of mental health services and the rights of the people receiving treatment in inpatient hospital care in Finland using the World Health Organization's QualityRights Tool Kit as a part of a randomized controlled trial VIOLIN. So far, reports on the QualityRights Tool Kit have mainly been from low- and middle-income countries or countries lacking resources for health services. Reports from countries with well-resourced health care systems, such as the Nordic countries, are still quite few.Methods: A cross-sectional observational survey was conducted on 13 closed inpatient psychiatric wards (acute, rehabilitation, forensic psychiatric) at eight hospitals in Finland. The data for the survey were gathered through a document review, observations, and group interviews among staff members, service users and family members. The STROBE checklist for cross-sectional studies was followed in the reporting.Results: Finnish mental health services are partially or fully achieving the standards set by the WHO QualityRights Tool Kit (final scores: 2.5-2.9 out of 3). The highest final score out of the five themes (2.9/3) was achieved under Freedom from torture or cruel, inhuman or degrading treatment or punishment and from exploitation, violence and abuse. The lowest final score out of the five themes (2.5/3) was achieved under the right to exercise legal capacity and the right to personal liberty and the security of person.Conclusions: According to the findings, Finnish mental health services appear to be of high quality. However, we have identified some gaps in quality, which we have addressed in a national randomized controlled trial VIOLIN. Improvements can be realized through shared decision making and relaying information to service users.</p

The Knowledge, Practice and Attitudes of Nurses Regarding Physical Restraint: Survey Results from Psychiatric Inpatient Settings

There is a considerable amount of literature describing how nurses' knowledge contributes to their attitudes and practices related to patient physical restraint. However, whether or not there have been any improvements in nurses' knowledge levels, attitudes or practices regarding physical restraint during the past few years is unknown. A survey was conducted on nurses (n = 133) in one psychiatric hospital in Hong Kong (n = 98, response rate = 74%). The data were analyzed using independent t-tests, ANOVA, a Mann-Whitney U test, a Kruskal-Wallis test and Spearman's rho. In general, nurses had good restraint-related knowledge with satisfactory attitudes and practices, although their knowledge levels, attitudes, and practices regarding restraint varied. Having a higher age, seniority, and education level contributed to a higher restraint-related knowledge level. Male nurses demonstrated more desirable practices (i.e., care of restrained patients), while nurses with a higher education level were more likely to avoid restraint. Nurses' restraint-related knowledge positively correlated with restraint practices. Although nurses' knowledge levels, attitudes, and practices regarding restraint were found to be satisfactory, more training efforts should focus on young nurses working in psychiatric settings with less work experience and lower education levels. As some nurses seem to favor the use of restraint with limited reflection, more studies are needed to verify nurses' emotions and how their emotions influence the use of restrictive practices

Challenges of foot self-care in older people: a qualitative focus-group study

BackgroundFoot health is an important aspect of general health, and it can be maintained and promoted through foot self-care. However, little is known about older people’s experiences of caring for their feet. The aim of this study was to gather knowledge about experiences of foot self-care from the perspective of healthy older people in order to improve their welfare and their management of foot health.MethodsA qualitative descriptive design with focus groups was used. Seventeen older people recruited from daytime activity centres participated in the focus groups (n = 4). The data were analysed using inductive content analysis.ResultsThe participants described their foot self-care as including various activities, but they were hindered by the following factors: physical (e.g. changes in nail structure), external (e.g. seeking help from multi-level professionals) and internal (e.g. related to ageing). Foot self-care was considered to be important, but it was not systematically carried out. The participants thought that health-care professionals neglected patients’ feet.ConclusionsOlder people use a variety of methods to care for their feet. However, several factors hinder their ability to do so. Older people need advice, education and support to maintain their foot health. Future research is needed to identify effective ways to support older people in foot self-care and improve their welfare as active citizens.</div

Violent events, ward climate and ideas for violence prevention among nurses in psychiatric wards : a focus group study

Background: Patient violence against nurses in their work environments is a widespread global concern, particularly in the field of mental health care. A high prevalence of violent events impacts the well-being of nurses and may also impair overall ward climate. However, it has been proposed that nurses' use limited techniques to prevent patient violence, and, therefore, more comprehensive methods for dealing with patient violence are needed. There is still restricted understanding of the ward climate during the occurrence of a violent event as well as how these incidents could be more effectively prevented. This study aimed to explore nurses' experiences of violent events in psychiatric wards, give insight into ward climates and examine suggestions for violence prevention. Methods: This study employed a descriptive, exploratory design including focus groups (n = 5) and open-ended questions. The participants were registered and enrolled nurses (n = 22) working on three closed psychiatric inpatient wards in one Finnish hospital district. Focus groups were tape-recorded, transcribed and analyzed with inductive content analysis. Results: Nurses' experiences of violent events included a variety of warning signs and high-risk situations which helped them to predict forthcoming violence. Patient-instigated violent events were described as complicated situations involving both nurses and patients. When the wards were overloaded with work or emotions, or if nurses had become cynical from dealing with such events, well-being of nurses was impaired and nursing care was complicated. Suggestions for violence prevention were identified, and included, for example, more skilled interaction between nurses and patients and an increase in contact between nurses and patients on the ward. Conclusions: This study revealed the complexity of violent events on psychiatric wards as well as the implications of these events on clinical practice development and training, administration and policy. A routine process is needed through which nurses' experiences and ideas concerning prevention of violent events are acknowledged.Peer reviewe

Nurses' perceptions of risks for occupational hazards in patient seclusion and restraint practices in psychiatric inpatient care: A focus group study

Seclusion and restraint are regularly used to manage patient aggression events in psychiatric inpatient care, despite occupational safety concerns. There is currently a lack of information on how nurses perceive the use of patient seclusion and restraint as a risk for occupational safety. The aim of this study is to describe the risks for occupational hazards in patient seclusion and mechanical restraint practices as well as ideas for improvement identified by nurses. A qualitative descriptive design was adopted, using focus groups comprising nurses (N = 32) working in psychiatric inpatient care. The data were analysed using inductive content analysis, and the results were reported using the consolidated criteria for reporting qualitative studies (COREQ). Four themes of risk for occupational hazards were identified: patient-induced, staff-induced, organization-induced, and environment-induced risks. One significant finding was that nurses described that their actions can strongly contribute to occupational hazards during seclusion and mechanical restraint practices. The nurses gave various ideas for how occupational safety could be improved during seclusion and mechanical restraint events, ideas involving staff, the organization, and environmental enhancements

Using the Dynamic Appraisal of Situational Aggression with mental health inpatients : a feasibility study

Purpose: This paper aims to explore the acceptability of Dynamic Appraisal of Situational Aggression (DASA) from the perspective of patients, its actual use by mental health nurses, and the predictive validity of the DASA instrument. Methods: A feasibility study design incorporating quantitative and qualitative components was used. The study was conducted in three mental health inpatient units at three hospitals in southern Finland. Quantitative data were used to explore demand (nurses' actual use of the DASA), limited efficacy (predictive validity), and acceptability (measured through patients' participation in the project). Qualitative data were collected to enhance the understanding of acceptability by describing patients' perceptions of the strengths and weaknesses of the DASA. Results: Nurses used the DASA for most patient assessments. The predictive validity of the DASA was outstanding or excellent, depending on the type of aggression predicted, although the patient recruitment ratio was low. Patients reported both strengths and weaknesses of the DASA, providing complementary information regarding the instrument's acceptability and clinical application. Conclusion: The DASA accurately predicts inpatient aggression. The patients' preferences and concerns regarding risk assessment have been noted. More patient involvement in risk assessment research and violence prevention efforts is required.Peer reviewe

Safety hazards in patient seclusion events in psychiatric care: A video observation study

Introduction: Seclusion is used to maintain safety in psychiatric care. There is still a lack of knowledge on potential safety hazards related to seclusion practices.Aim: To identify safety hazards that might jeopardize the safety of patients and staff in seclusion events in psychiatric hospital care.Method: A descriptive design with non-participant video observation was used. The data consisted of 36 video recordings, analysed with inductive thematic analysis.Results: Safety hazards were related to patient and staff actions. Patient actions included aggressive behaviour, precarious movements, escaping, falling, contamination and preventing visibility. Staff actions included leaving hazardous items in a seclusion room, unsafe administration of medication, unsecured use of restraints and precarious movements and postures.Discussion: This is the first observational study to identify safety hazards in seclusion, which may jeopardize the safety of patients and staff. These hazards were related to the actions of patients and staff. Implications for Practice Being better aware of possible safety hazards could help prevent adverse events during patient seclusion events. It is therefore necessary that nursing staff are aware of how their actions might impact their safety and the safety of the patients. Video observation is a useful method for identifying safety hazards. However, its use requires effort to safeguard the privacy and confidentiality of those included in the videos.</p

An Evidence-Based Educational Intervention for Reducing Coercive Measures in Psychiatric Hospitals: A Randomized Clinical Trial

Importance  Investing in health care staffs’ education can change the scope of action and improve care. The effectiveness of staff education remains inconclusive.Objective  To examine whether an evidence-based educational intervention for nurses decreases the use of seclusion rooms in psychiatric hospitals compared with usual practice.Design, Setting, and Participants  In this pragmatic, 2-arm parallel, stratified cluster randomized clinical trial, 28 wards in 15 psychiatric hospitals in Finland were screened for eligibility and randomly allocated (1:1). Nurses joined on either intervention (n = 13) or usual practice (n = 15) wards. The intervention was performed from May 1, 2016, to October 31, 2017. The follow-up data for January 1 to December 31, 2017, were collected from hospital registers in 2018. Data analysis was performed October 27, 2021.Interventions  Evidence-based education delivered during 18 months, including 8 months of active education, followed by a 10-month maintenance period.Main Outcomes and Measures  The primary outcome was the occurrence of patient seclusion (events per total number of patients).Results  Of 28 psychiatric hospital wards screened (437 beds and 648 nurses), 27 wards completed the study. A total of 8349 patients were receiving care in the study wards, with 53% male patients and a mean (SD) age of 40.6 (5.7) years. The overall number of seclusions was 1209 (14.5%) in 2015 and 1349 (16.5%) in 2017. In the intervention group, the occurrence rate of seclusion at the ward level decreased by 5.3% from 629 seclusions among 4163 patients (15.1%) to 585 seclusions among 4089 patients (14.3%) compared with a 34.7% increase from 580 seclusions among 4186 patients (13.9%) to 764 seclusions among 4092 patients (18.7%) in the usual practice group. The adjusted rate ratio was 0.86 (95% CI, 0.40-1.82) in 2015 and 0.66 (95% CI, 0.31-1.41) in 2017 (P = .003). However, the number of forced injections increased in the intervention group from 317 events among 4163 patients (7.6%) in 2015 to 486 events among 4089 patients (11.9%) in 2017 compared with an increase in the usual practice group from 414 events among 4186 patients (9.9%) in 2015 to 481 events among 4092 patients (11.8%) in 2017. Seven adverse events were reported.Conclusions and Relevance  In this randomized clinical trial, the educational intervention had a limited effect on the change of occurrence rate of patient seclusion, whereas the use of forced injections increased. More studies are needed to better understand the reasons for these findings.</p