Mental health in psychiatric hospitals
AGGRESSION AND Violence are often cited as a major occupational hazard in health care facilities [Byrnes 2000, Lipscomb and Love 1992 and Rippon 2000]. A survey conducted by the American Nurses Association in 2001 found that 25% of nurses named on the job assault as a great concern; 17% had been physically assaulted in the past year and more than half (57%) were threatened verbally or verbally abused [American Nurses Association 2001]. Attracting the attention of the Office of Health & Safety, injury rates to nurses in public sector psychiatric facilities from violence alone are twice as high as injury rates from all causes reported in traditionally high risk industries [Love and Hunter 1996]. These numbers are surprising, given that no standards exist for measuring and reporting mechanisms in health care, resulting in a gross underreporting of assaults [Lion et al 1981].
The lack of research based violence prevention standards from which to work has left thousands of nurses working in hazardous conditions with few reliable resources at their disposal to prevent and effectively manage violence toward themselves, their coworkers or patients in health care settings. The severity of the problem in psychiatric facilities and consequences of assaults and injuries are well documented. For example, [Love and Hunter 1996] documented staff injury rates in six state psychiatric hospitals that ranged from 11.7 to 16.9 injuries per 100 employees. Aggression and violence is both costly to the institution [Hunter and Carmel 1992] and results in considerable psychological sequella for the staff [Duxbury 1999, Lanza 1984, Lanza 1992, Love and Hunter 1996, Poster and Ryan 1989 and Ryan and Poster 1989]. Nurses assaulted by their patients may experience loss of time from work, financial costs and protracted psychological sequella, including a variety of posttraumatic stress responses. In one study the costs to one hospital for an assault in terms of lost time and legal fees was approximately $250,000 [Hunter and Carmel 1992]. However, despite these consequences for aggression and violence, institutional and individual roadblocks still exist which interfere with the examination of causes of aggression and violence and effective interventions or prevention programs. For example, denial by administrators that violence exists and an attitude that “its part of the job” by the front line staff often perpetuate an unwillingness to address the issue [Lion 1987 and Maier 1999]. A fear of liability may also inhibit administrators from exploring the scope of the problem or from developing effective interventions. The dependent nature of these institutions on the public sector for policy and financial direction contributes to the situation by fostering a status quo or don’t rock the boat attitude.
Several interventions for violence have received some, but insufficient attention in the literature: seclusion and restraints [Brooks 1987, Brown and Tooke 1992 and Soloff et al 1985], medications [Corrigan et al 1993], limit setting [Gallop 1990 and Gallop 1993], de-escalation [Morales and Duphorne 1995 and Stevenson 1991], and the need for training [Barile 1982, Carmel and Hunter 1990, Grube 2001, Hurlebaus and Link 1997, Infantino and Musingo 19, Lehman et al 1983, Lion 1987, Martin 1995 and Nigrosh 1983]. Unfortunately, this literature is not often theory or researched based and it does not provide sufficient direction for managing the problem. In most cases, it expresses expert clinical opinion and leaves the question of intervention effectiveness begging.
Because of the scope of the problem, the Office of Safety and Health Administration (OSHA), recommended guidelines for health care facilities to provide education on the management of aggressive behavior. Psychiatric facilities now implement formal education for the nursing staff on a yearly or biannual basis in the management of aggressive behavior (MAB). This need for training has resulted in a small cottage industry of mental health consultants selling a program usually based on some martial arts program. Although some of these programs are excellent, not all are based on sound professional and clinical principles and very little is publicly known about the results of scientific study of these programs. Our goal with this report is to evaluate several commonly used programs for the management of aggressive behavior using a set of predetermined criteria.
Literature review
Very little literature exists on the topic of training staff for the management of aggressive behavior in psychiatric facilities, which is interesting, considering the importance of the topic. [Lehman et al 1983] first showed that training staff in the prevention of violence, and methods of verbal and physical de-escalation techniques led to improved knowledge about and confidence in handling violent situations. Shortly after, [Infantino and Musingo 19] took the study of training one step forward to measure a specific staff outcome such as, injuries. The results showed that training led to a statistically significant reduction in injuries. By the late 1980s programs for the management of aggressive behavior were already widely in use in the Unites States, when [Lion 1987] added his voice to the literature. Lion advocated that the American Psychiatric Association develop policies and regulate staff education for aggression management; requiring all professionals to attend. Unfortunately Lion used a metaphor to reflect staff-patient relationships, “training for battle” which contributed to an adversarial attitude between staff and patients that continues in some places today.
Two facilities have implemented staff training as part of a long-term program designed to decrease violence in a maximum security, forensic psychiatric facility [Carmel and Hunter 1990, Love and Hunter 1996 and Rice et al 1989]. At Atascadero Hospital in California, violence is viewed as an occupational issue resulting in a “no violence” policy. The problem is addressed using the Quality Improvement Methods specified by [Deming 1986] focusing on staff injury rates. One study from Atascadero showed that units with high staff compliance in training had statistically fewer injuries than units that had low compliance with training [Carmel and Hunter 1990]. But staff with compliance in CPR training also had significantly lower injury rates, suggesting that some aspect of group cohesion or the Hawthorne effect might account for the decrease in injury rates, not training. In contrast, Rice’s group approached the problem from a research perspective measuring not only knowledge and confidence levels of staff, but also assaultive levels of patients. The results showed an initial significant reduction in assaults after training, followed by an increase in assaults [Rice et al 1989].
Tags: Health Hunter