Associations between violence, self‐harm and acute psychiatric service use: Implications for inpatient care

Abstract

Accessible Summary What is known on the subject? Service users who behave violently may suffer. This is because violence can lead to unnecessary medication, seclusion on the ward and strained relationships with other people. It can also affect a service user's self‐esteem and lead to feelings of shame. Service users who behave violently can also make life frightening and unpredictable for members of staff, and other service users on the ward. It is important to gain a sound understanding of violence in order to help reduce it. What the paper adds to existing knowledge? Previous research has shown that having a past history of violence, being admitted to PICU and being admitted to hospital under section is associated with violent behaviour on the ward. We identified several new factors associated with violent behaviour, such as engaging in self‐harm, being the target of another person's violence and being referred to a Psychiatric Liaison Team. Implications for practice For some service users, behaving violently may be a response to previous trauma and an expression of distress. It is therefore important that mental health nurses are supported by their employers to work with service users in a trauma‐informed manner. Nurses employed across a range of psychiatric settings could benefit from direct interventions such as comprehensive trauma‐informed care training and psychological debrief spaces, or systemic interventions to address staff shortages and improve ward conditions. Abstract Introduction Instances of violence in acute psychiatric settings are frequent, can be devastating for service users and staff, and are costly. Such settings would benefit from a greater understanding of violence. Aim We analysed the association between current and historical variables and rates of inpatient violence. To address gaps in current research, we included instances of self‐harm and being the target of violence. We also included seldom used service metrics. Method Data were extracted on admissions to acute adult wards and PICUs 2017–2020 within South London and Maudsley NHS Foundation Trust. A zero‐inflated negative binomial regression mixed model was used to analyse the impact of variables on rates of violence. Results Variables associated with an increased rate of violence were as follows: an increased number of violent incidents in the year before admission, being admitted on MHA section, being admitted to PICU, instances of self‐harm, being the target of violence and referral to a Psychiatric Liaison Team. Discussion The novel associations found between enacting violence, self‐harm and being the target of violence indicate trauma‐informed care is crucial to reduce violent presentations of distress. Implications for practice System level interventions are crucial to ensure mental health nurses are supported to provide trauma‐informed care.

An analysis of Chinese nursing electronic medical records to predict violence in psychiatric inpatients using text mining and machine learning techniques

“…Consistent with those of other studies [9,[13][14][15][16][17][18][19], our findings indicated that a younger age [14,15,29], history of violence [16,17,23], and unmarried status [18,19] are related to patients demonstrating violence in psychiatric wards. In a review by Cornaggia et al [9], the researchers concluded that being admitted involuntarily, the existence of previous aggressive episodes, having a longer hospitalization stay, being impulsive, misusing drugs or alcohol, having a younger age, and having a diagnosis of psychosis were associated with inpatient aggression/violence.…”

Reducing violence and aggression: a quality improvement project for safety on an acute mental health ward

“…Patient factors affecting V&A on mental health wards include admission under the MHA,35 36 younger age6 37 and illicit drug use 6 38 39. A variable strongly correlated with V&A is history of aggression40 41 and a recent study found 4% of service users accounted for 50% of V&A 19. Epidemiological studies of violence and serious mental illness have shown low risk for violence associated with serious mental illness unless there is a comorbidity with illicit substance misuse 10 11.…”

“…This can have a knock-on effect on patient care 17. There are also financial costs associated with assaults, verbal abuse and damage to property with an estimated annual cost of £20.5 million per year in psychiatric wards in England,18 this can result in more acute service use including internal transfers and increased occupied bed days 19…”

Consistency of Violence: Implications for Effective Inpatient Psychiatric Care

“…For healthcare professionals, frequently witnessing or being targeted by violence and aggression can lead to burnout, which aside from being distressing to experience may have a detrimental impact on healthcare professionals' ability to provide compassionate care (Foster et al, 2007). An improved understanding of violence and aggression is therefore key to developing preventative measures to alleviate distress caused (McIvor et al, 2022). There is variation in the reported proportion of inpatients enacting violence and aggression on acute psychiatric wards, with study estimates ranging between 17-40% (Iozzino et al, 2015;Lockertsen et al, 2020).…”

“…Though often necessary, the decision to detain someone is ultimately subjective and depends on structural influences (e.g. level of pressure experienced by services) and the therapeutic relationship and interaction between doctor and service user (McIvor et al, 2022). The two most common types of section for those detained on acute psychiatry wards are 'admission for assessment' (lasting a maximum of 28 days) and 'admission for treatment,' (lasting for a maximum of six months before renewal is needed).…”