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Royal College of Psychiatrists’Research and Training Unit, 4th Floor Standon House, 21 Mansell Street, London E1 8AA, email: rchaplin{at}cru.rcpsych.ac.uk
Royal College of Psychiatrists’ Research and Training Unit, London E1 8AA
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Abstract |
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 Top Abstract IntroductionMethodResultsDiscussionReferences |
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We audited 184 psychiatric wards against clinical practice guidelines for the management of violence. Staff and service users completed anonymous questionnaires. Environmental inspections were performed by two teams.
RESULTS
There were 4460 questionnaires returned. Nurses (78%) were significantly more likely to report the experience of violence than service users (37%). Drugs were reported by 72% of nurses and alcohol by 61% as causing problems. Other standards frequently not met included staffing levels, training, provision of activities, ward design and ambience.
CLINICAL IMPLICATIONS
Specific issues are identified that must be addressed by national and local action. A baseline is set against which the impact of this action can be judged. Priorities must include tackling drug and alcohol use in psychiatric wards.
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Introduction |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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The National Audit of Violence in mental health in-patient settings was funded by the Healthcare Commission. It repeats an earlier audit conducted on a smaller scale (McGeorge et al, 2001) that showed high rates of violence against service users, and highlighted problems with staff training, drug and alcohol use and ward environments. The audit standards, drawn from clinical practice guidelines published by the Royal College of Psychiatrists (1998), were revised to incorporate new recommendations by the group developing the National Institute for Clinical Excellence (NICE) guidelines (NICE, 2005). Data collection for the audit began in Spring 2004. This paper presents the main findings of the National Audit of Violence for wards for adults of working age (Healthcare Commission, 2005).
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Method |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Questionnaires
A questionnaire for service users and one for staff were used to determine
the factors linked to in-patient safety and violence. These were completed
between April and August 2004 and returned anonymously to the College Research
and Training Unit. Staff were categorised as nurses, or other clinical
(doctors, psychologists, pharmacists, etc.) or non-clinical (e.g.
administrators, maintenance staff, porters) staff. Each questionnaire
contained a mixture of closed (‘Yes/No’) questions and boxes for
free-text comments. Each local project team was encouraged to devise its own
strategy for targeting staff and service users in order to maximise the
response but preserve confidentiality. It was therefore not possible to
calculate the refusal rate.
Inspections
Two teams, one of staff from the ward concerned and the other of people who
did not work on that ward (trust managers, service user advocates, etc.),
inspected and rated each ward independently against a set of evidence-based
standards relating to the safety of the physical environment. This was carried
out between September and October 2004 and ended with a meeting of the two
teams to agree the final ratings.
In addition, information was collected about staffing, including the use of agency and bank staff in the week leading up to the audit. The data collection was supplemented by information about local ward conditions and obstacles to improvement gathered at regional events at which staff from participating wards met to consider the audit methods and findings.
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Results |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Experience of violence of service users and staff
Approximately three-quarters of nurses (78%) reported that they had been
subject to violence, threats or been made to feel unsafe
(Table 1). This was
significantly more than service users (37%, 
2=1259, d.f.=3,
P<0.001), other clinical staff (44%; 2=220,
d.f.=3, P<0.001) and non-clinical staff (33%,
2=261, d.f.=3, P<0.001). The other results drawn
from the returned questionnaires relate to service users and nurses (i.e. they
exclude other staff groups).
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Potential triggers of violence
The audit questionnaires enquired about a range of factors that are linked
to violence. Of these, staff appeared to be particularly concerned about drug
and alcohol use. Drugs were reported to cause trouble by 72% of nurses and
alcohol by 61% (Table 1).
Service users were less likely than nurses to report drugs (29%;
2=629, d.f.=1, P<0.001) or alcohol (25%;
2=434, d.f.=1, P<0.001) to be a problem. However,
many service users did report being bored. Although 63% were satisfied with
daytime activities and therapy, only 47% expressed satisfaction with evening
activities and 41% with activities during the weekend.
Free-text comments about triggers to violence were made by 185 staff and 170 service users. For both groups, illegal drugs and alcohol were mentioned most frequently (by 54 staff and 27 service users). Other issues for staff included inadequate staff numbers (n=34) or training or experience (n=25) and overcrowding (n=10). Some service users (n=19) reported that staff inadvertently provoke violence by their negative attitudes or by restricting patients’ freedom (n=15). Consistent with this, 36% of service users answered yes to the question ‘do staff ever wind you up?’
Staffing and the management of violence
Most service users had a high opinion of staff and reported that they were
available to speak to (83%) and treated them with respect (85%). Most (86%)
also agreed that staff dealt effectively with violence between service users,
an opinion that was shared by 94% of nurses. Nurses rated highly their support
from other staff (overall rate 86%) and satisfaction with communication with
colleagues (79%). However, only 57% of nurses were satisfied with the number,
skills experience and qualifications of the staff team. Free-text responses
reported problems such as inadequate staffing, inexperienced leadership,
difficulties with recruiting nurses and an overreliance on bank and agency
staff. Ward managers estimated that agency and bank staff had worked an
average of 100 h on the ward in the week before the audit. This is equivalent
to a mean of 2.7 full-time members of staff per ward.
Although 90% of nurses had received some training in the prevention or management of violence in the past 5 years, 39% had had no training before they started working on the ward. Of those who had received training, 20% reported that it was inadequate to equip them to manage violence.
The physical environment
Nurses were generally more critical of the physical environment and ward
ambience than service users (Table
1). Several safety issues were highlighted by the environmental
audit. Only 36% of wards were judged to have adequate sight lines, 48% had
exits that could be seen by staff and 46% had adequate private space. Although
80% of wards had access to outside activity areas, in only 40% was there
covered external space, and a separate, low-stimulus quiet area was provided
in only 59% of wards. Adequate temperature and ventilation control was judged
to be present in only 33% of wards.
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Discussion |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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The audit highlights that, although nurses are most at risk, the experience of violence is not limited to those who work exclusively on the wards or whose job it is to intervene in violent incidents. Medical and ancillary staff are also affected. The causes of violence are complex and service users emphasised different factors from nurses.
The key messages arising from this audit are:
Some of the problems identified by the audit require organisational or system changes. Difficulties in staff recruitment and low morale may arise as a result of the experience of violence or lead to increased violence. However, this audit does not support the latter, as both service users and nurses gave consistently high ratings for the way staff managed violence. The status of in-patient nursing must be raised to reduce the exodus of nurses to community posts and so reduce reliance on bank and agency nurses. Only if staff duties are reorganised can nurses spend more time in face-to-face contact with service users. This would both increase therapeutic and occupational activities and reduce boredom among service users, and probably improve staff morale. The open nature of acute psychiatric wards and rapid patient turnover make it difficult to prevent drugs and alcohol getting onto the ward (Quirk et al, 2006). Creative solutions are needed to limit access to drugs and alcohol without compromising patient freedom and choice.
Although the audit standards were chosen because of their link to ward safety, many are also measures of ward quality. The audit therefore sets a baseline against which the impact of national and local action to improve English psychiatric wards can be gauged. This action is backed by £30 million of additional funding (Department of Health, 2004) and a raft of guidance about many aspects of ward design, ward safety and the management of violence (Department of Health, 2002; Marshall et al, 2004; NICE, 2005).
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References |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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DEPARTMENT OF HEALTH (2002) Mental Health Policy Implementation Guide: Adult Inpatient Care Provision. London: Department of Health.
DEPARTMENT OF HEALTH (2004) The National Service Framework for Mental Health - Five Years On. London: Department of Health.
HEALTHCARE COMMISSION (2005) The National Audit of Violence (2003-2005). Final Report. http://www.healthcarecommission.org.uk/_db/_documents/04017451.pdf
LELLIOTT, P. (2004) The National Patient Safety
Agency. Psychiatric Bulletin,
28, 193
-195.
MARSHALL, H., LELLIOTT, P. & HILL, K. (2004) SaferWards for Acute Psychiatry. London: National Patient Safety Agency. http://www.npsa.nhs.uk/site/media/documents/1241_SWAP_ResearchReport.pdf
McGEORGE, M., LELLIOTT, P. & STEWART, J. (2001) Managing violence in psychiatric wards: preliminary findings of a multi-centres audit. Mental Health Care, 31, 366 -369.
NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE (2005) Violence: The Short Term Management of Disturbed/Violent Behaviour in Inpatient Psychiatric Settings and Emergency Departments. London: NICE. http://www.nice.org.uk/page.aspx?o=cg025fullguideline
PIETERS, G., SPEYBROUCK, E., DE GUCHT, V., et al
(2005) Assaults by patients on psychiatric trainees: frequency
and training issues. Psychiatric Bulletin,
29, 168
-170.
QUIRK, A., LELLIOTT, P. & SEALE, C. (2006) The permeable institution: an ethnographic study of three acute wards in London. Social Science and Medicine, 63, 2105 –2117.
ROYAL COLLEGE OF PSYCHIATRISTS (1998) The Management of Imminent Violence: Clinical Practice Guidelines to Support Mental Health Services (Occasional Paper OP41). London: Royal College of Psychiatrists.
WILDGOOSE, J., BRISCOE, M. & LLOYD, K. (2003)
Psychological and emotional problems in staff following assaults by patients.
Psychiatric Bulletin,
27, 295
-297.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
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