Seclusion of patients on psychiatric wards is a controversial intervention with serious safety issues for patients. Nurses have an important role in the decision to use seclusion when encountering aggressive behaviour. The aim of this thesis is to improve knowledge about the influence of nurses on the incidence of aggressive behaviour and the use of seclusion, in order to use that knowledge to prevent such events in the future. Patients and nurses share views on the factual cause of aggressive behaviour, but their perception of the severity differ. The attitude of nurses towards seclusion changed over the last decades from a therapeutic paradigm to a safety paradigm. In our study, teams with majority of male nurses were associated with less seclusion and aggressive behaviour. Teams with high scores on personality trait openness were associated with less seclusion and teams with high scores on personality trait extraversion were associated with patients’ aggression. There are no golden solutions to improve safety of psychiatric wards, but increased attention of development of nursing skills seems as an important step forward. By providing optimal nursing care, vulnerable patients on psychiatric wards receive the care they deserve.
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BACKGROUND Seclusion is an intervention widely used in Dutch mental health care. The intervention can be effective in acute situations to avert (further) aggression or self-harm. However, seclusion is also a controversial intervention that may not have any positive effect with regard to symptom improvement. In general patients report negative effects after being secluded e.g. anxiety and having had a traumatic experience.The main reason for seclusion is not manageable aggressive behaviour of a patient. Earlier studies reported several risk factors that may contribute to seclusion, regarding patients’ characteristics, but also with regard to staff characteristics, working protocols and unit characteristics. Because of unequivocally results there is the need for a longitudinal prospective study to examine staff- and unit determinants in association with seclusion.AIMS The objective of this study is to determine which nursing staff and unit characteristics are associated with seclusion following aggression in hospitalized adult psychiatric patients. We hope to create a predictive model to estimate the risk of seclusion on an acute psychiatric ward.METHODS We will conduct a prospective observational study on a closed psychiatric ward of an academic hospital. Patients are aged 18 – 65 years and are admitted when their psychiatric condition leads to an immediate threat to the patient themselves or their surroundings.All nurses on the ward are all qualified nurses and registered in the Dutch registration of healthcare professionals. They are trained every six months in techniques of verbal de-escalation and safe physical restraint. For both nurses and the patients baseline characteristics are monitored. Every shift (day, evening, night) data are gathered on the patients, nurses and unit. Data are retrieved from the electronic patient chart, including information of the Brøset Violence Checklist. Furthermore, the exchange of information among nurses is measured using the Grid instrument. Data will be analysed using multilevel regression analysis. Data will be collected for a period of 2 years, which started January 2013.RESULTS The primary endpoint in our study is the incidence of seclusion. As a secondary endpoint, the duration of the seclusion is measured. These endpoints are measured using the Argus registration system and will be linked to predictors of seclusion, with special focus on the nursing staff- and unit determinants.
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Forensic psychiatric inpatients are frequently exposed to aggression from fellow patients during their treatment, but research on how this impacts patients’ well-being and treatment progress is lacking. In this study, we interviewed nine patients on their experiences of victimization during mandatory psychiatric treatment. The interviews were analyzed using a Grounded Theory approach combined with elements from Consensual Qualitative Research and Interpretative Phenomenological Analysis. Three main themes emerged from the data, namely situational descriptives, intrapersonal and interpersonal consequences. Patients were not only exposed to both physical violence and verbal aggression by other patients, but also to a more ubiquitous flow of micro- aggressive comments. Options to escape these situations were limited. This means that victimization processes, which for most patients started much earlier in life, continue during forensic psychiatric treatment. Intrapersonal consequences include fear, hypervigilance, reactive aggression, flashbacks and avoidance and withdrawal. Interpersonal consequences include increased power differences between patients and adverse treatment consequences, such as difficulties with self-esteem. Victimization processes are not always timely noticed in an environment that focuses on risks and treatment of delinquent behavior. A higher level of trauma sensitivity in forensic mental health care is thus required. Recommendations for the implementation of trauma informed care are provided.
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