Care planning for aggression management in a specialist secure mental health service: An audit of user involvement

Abstract

This paper describes an audit of prevention and management of violence and aggression care plans and incident reporting forms which aimed to: (i) report the compliance rate of completion of care plans; (ii) identify the extent to which patients contribute to and agree with their care plan; (iii) describe de‐escalation methods documented in care plans; and (iv) ascertain the extent to which the de‐escalation methods described in the care plan are recorded as having been attempted in the event of an incident. Care plans and incident report forms were examined for all patients in men's and women's mental health care pathways who were involved in aggressive incidents between May and October 2012. In total, 539 incidents were examined, involving 147 patients and 121 care plans. There was no care plan in place at the time of 151 incidents giving a compliance rate of 72%. It was documented that 40% of patients had contributed to their care plans. Thematic analysis of de‐escalation methods documented in the care plans revealed five de‐escalation themes: staff interventions, interactions, space/quiet, activities and patient strategies/skills. A sixth category, coercive strategies, was also documented. Evidence of adherence to de‐escalation elements of the care plan was documented in 58% of incidents. The reasons for the low compliance rate and very low documentation of patient involvement need further investigation. The inclusion of coercive strategies within de‐escalation documentation suggests that some staff fundamentally misunderstand de‐escalation.

Safewards: Changes in conflict, containment, and violence prevention climate during implementation

“…2014), and on empirical studies (Hallett & Dickens 2015; Hallett et al . 2016). In its initial UK validation study, it was found to have good psychometric properties including internal reliability, convergent validity, and test–retest reliability.…”

Recovery‐focussed care: How it can be utilized to reduce aggression in the acute mental health setting

“…; Hallett et al . ), and many believe that exposure to aggression is an expected ‘part of the job’ (Baby et al . , p. 649) when working with people with acute mental illness.…”

“…The frequent occurrence of aggression could lead mental health professionals to view their roles negatively, use extended periods of sick leave, or resign (Edward et al 2014). Mental health nurses (hereafter referred to as 'nurses') are frontline professionals in managing aggression (Boardman & Roberts 2014;Bowers et al 2009;Hallett et al 2016), and many believe that exposure to aggression is an expected 'part of the job' (Baby et al 2014, p. 649) when working with people with acute mental illness. This belief could lead nurses to view the causes of aggression as predominantly related to the person's psychiatric symptoms or complex pre-existing personality issues (Bowers 2014;Irwin 2006).…”

“…Finally, nurses' choice of responses might be influenced by the service's culture of care Livingstone 2007). This is reinforced by Hallett et al (2016), who identified that the use of PRN medication as a de-escalation method for aggression was often embedded in a service's culture of care. Yet the use of these potentially-restrictive strategies, such as PRN medications, reduce the person's ability to self-regulate, and might leave them feeling disempowered with little control over what was happening to them (Boardman & Roberts 2014;Cornaggia et al 2011;Pulsford et al 2013).…”

“…Following the assessment, a management and safety plan should be developed with the consumer to mitigate or reduce any identified risks (Dickens et al 2013;Ferns 2007;Padmore & Roberts 2013;Singh et al 2014;Sturup et al 2013). This plan should include both nurseassisted support strategies, as well as consumer selfregulating capabilities (Foster et al 2007;Hallett et al 2016;Pulsford et al 2013). This approach fosters improved communication between the nurse and the consumer, increases their feelings of safety, and encourages the nurse to engage in RFC.…”