Violence and aggression in psychiatric inpatient care in Sweden: a critical incident technique analysis of staff descriptions

Abstract

Background: Violence towards staff working in psychiatric inpatient care is a serious problem. The aim of the present study was to explore staff perspectives of serious violent incidents involving psychiatric inpatients through the following research questions: Which factors contributed to violent incidents, according to staff? How do staff describe their actions and experiences during and after violent incidents? Methods: We collected data via a questionnaire with open-ended questions, and captured 283 incidents reported by 181 staff members from 10 inpatient psychiatric wards in four different regions. We used the Critical Incident Technique to analyse the material. Our structural analysis started by structuring extracts from the critical incidents into descriptions, which were grouped into three chronological units of analyses: before the incident, during the incident and after the incident. Thereafter, we categorised all descriptions into subcategories, categories and main areas. Results: Staff members often attributed aggression and violence to internal patient factors rather than situational/relational or organisational factors. The descriptions of violent acts included verbal threats, serious assault and death threats. In addition to coercive measures and removal of patients from the ward, staff often dealt with these incidents using other active measures rather than passive defence or de-escalation. The main effects of violent incidents on staff were psychological and emotional. After violent incidents, staff had to continue caring for patients, and colleagues provided support. Support from managers was reported more rarely and staff expressed some dissatisfaction with the management. Conclusions: As a primary prevention effort, it is important to raise awareness that external factors (organisational, situational and relational) are important causes of violence and may be easier to modify than internal patient factors. A secondary prevention approach could be to improve staff competence in the use of de-escalation techniques. An important tertiary prevention measure would be for management to follow up with staff regularly after violent incidents and to increase psychological support in such situations.

Aggressive Behavior and Psychiatric Inpatients: a Narrative Review of the Literature with a Focus on the European Experience

“…Victims of physical aggression-leaving aside physical damage-can report a vast array of psychological consequences, whose seriousness ranges from adjustment symptoms up to posttraumatic stress disorders [123•, 124]. Verbal aggression has been found to produce angst, depression, and other emotional distress, with repercussions on morale, professional replacement, quality of care, and patient recovery processes [125][126][127].…”

Safety in Residential Youth Facilities: Staff Perceptions of Safety and Experiences of the “Basic Training Program in Safety and Security”

“…Studies of violence management at youth inpatient facilities in a Nordic context have concluded that a supportive team of staff members who share common beliefs is vital (Pelto-Piri et al, 2017), as are preventive approaches (Pelto-Piri et al, 2020). First, external factors (organizational, situational, and relational) are significant causes of violence and may be easier to modify than internal youth factors.…”

“…Second, improving staff competence in the use of deescalation techniques is essential. Third, management should regularly follow up with staff after violent incidents and increase psychological support (Pelto-Piri et al, 2020).…”

Profiling referrals to a trauma support service: needs and outcomes for staff working in a secure adult developmental disorder pathway

“…The particular vulnerability for trauma in staff working within forensic DD services represents a major clinical concern. For staff, research has documented adverse impacts on work functioning and burnout (Oates et al, 2020), levels of anxiety and depression (d' Ettore and Pellicani, 2017), perceptions of safety (Pelto-Piri et al, 2020) and physical health (Kelly et al, 2016). Such adversities may also translate into consequences for service users, resulting in poorer quality of care (Arnetz and Arnetz, 2001) and a longer length of stay in services (Broderick et al, 2015).…”

“…There is substantial evidence demonstrating the benefits of work-based counselling, for both the individual affected and the organisation within which they work (Greenwood, 2006), preventing the worsening of psychopathological symptoms and improving work functioning (Klaver et al, 2020). Yet, whilst the need for personal and emotional support for staff working in such settings is recognised in clinical guidance (National Institute for Health and Care Excellence, 2015), the actual provision of post-incident support within forensic and health-care settings is less documented (Pelto-Piri et al, 2020), and self-care behaviours to combat work-related stress are not frequently practiced by staff (Keesler and Troxel, 2020). Therefore, insight into the levels of access to trauma support for staff working in DD settings and the associated outcomes for this particularly at-risk group is key.…”