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The psychiatric hospital environment plays a significant, though often underappreciated, role in patient and staff functioning. This column reviews the literature on important environmental and therapeutic issues in psychiatric hospital design. Research findings and clinical conjecture reported over the past 50 years indicate that intervening environmentally through clinically informed, patient-centered design can improve functioning both among and between patients and staff. This column identifies specific best practice considerations and recommendations for designing inpatient psychiatric facilities and may serve as a useful planning resource to those interested in adopting a patient-centered, inclusive approach to design and treatment.

BACKGROUND A study by Hesketh et al. found that 20% of psychiatric nurses were physically assaulted, 43% were threatened with physical assault, and 55% were verbally assaulted at least once during the equivalent of a single work week. From 2005 through 2009, the U.S. Department of Justice reported that mental health occupations had the second highest average annual rate of workplace violence, 21 violent crimes per 1,000 employed persons aged 16 or older. OBJECTIVE An evaluation of risk factors associated with patient aggression towards nursing staff at eight locked psychiatric units. PARTICIPANTS Two-hundred eighty-four nurses in eight acute locked psychiatric units of the Veterans Health Administration throughout the United States between September 2007 and September 2010. METHODS Rates were calculated by dividing the number of incidents by the total number of hours worked by all nurses, then multiplying by 40 (units of incidents per nurse per 40-hour work week). Risk factors associated with these rates were analyzed using generalized estimating equations with a Poisson model. RESULTS Combining the data across all hospitals and weeks, the overall rate was 0.60 for verbal aggression incidents and 0.19 for physical aggression, per nurse per week. For physical incidents, the evening shift (3 pm – 11 pm) demonstrated a significantly higher rate of aggression than the day shift (7 am – 3 pm). Weeks that had a case-mix with a higher percentage of patients with personality disorders were significantly associated with a higher risk of verbal and physical aggression. CONCLUSION Healthcare workers in psychiatric settings are at high risk for aggression from patients.

A statewide sample of WWII ex‐POWs (N = 442) responded to questionnaires that sampled current and past difficulties with PTSD‐related symptoms; an incidence of serious difficulties with these symptoms of 56% was revealed. Retrospective reports of temporal patterns revealed no consistent patterns of symptom occurrence, but, rather, a waxing and waning of difficulties over the 40‐year period. Unexpectedly, measures of severity of the POW experiences did not predict current symptomatology. Rank at time of capture, however, was consistently and strongly predictive of PTSD. It is suggested that PTSD is a highly persistent phenomenon and that both situation and person variables contribute to the development and maintenance of PTSD.

Sexually inappropriate behaviors in clinical settings are relatively common occurrences that may negatively affect the therapeutic process. For example, more than half of female psychologists have reported at least 1 incident in which a client responded in a sexually inappropriate manner. Thus, it is important for clinicians to understand inappropriate behaviors and respond in a manner that is both personally satisfying and helpful to the client. A framework for conceptualizing these behaviors is proposed, as well as components for, and examples of, therapeutic responses. Recommendations are provided for preventive measures to decrease the likelihood of inappropriate behaviors and for systemic approaches to benefit professional training in regards to these issues. Our aim is to stimulate further discussion of sexually inappropriate behaviors specifically by facilitating psychotherapists' ability to address clients' within-session sexual behavior, facilitating speculation of the antecedents of and motivations behind such behaviors, and facilitating discussion of such behaviors within supervision and, more broadly, within training programs.

Psychiatric nurses are frequent victims of workplace violence, much of which is perpetrated by patients. In a review of literature on prevalence, perpetrators, and impact of violence on psychiatric nurses, we note that workplace violence is a virtually normative experience for the nurse, rather than a rare occurrence. Verbal violence and sexual harassment, like physical violence, are common experiences; in contrast to physical violence, these are often initiated by co-workers. The emotional impact of violence on psychiatric nurses is studied less often than frequency of exposure; we discuss hypotheses for this paucity of relevant research. Finally, we reflect on the implications of current research, concluding with recommendations for future research on violence against psychiatric nurses. In particular, we elaborate on the role of violence research in the healthcare setting as "sensitive research"--a research process that in itself may have both direct and indirect beneficial effects for the nursing profession.

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