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Safety Issues in Psychiatric Settings
VARSTVOSLOVJE, Journal of Criminal Justice and Security year 13
pp. 431-443
no. 4
Tinkara Pavsic Mrevlje, Peter Umek
Purpose:
The purpose of the paper is to establish if mental health workers (nurses, doctors, clinical psychologists) in Slovene psychiatric settings perceive their work as potentially dangerous and which factors contribute mostly to these mindsets. On the basis of gained data recommendations for safety improvement are suggested. Design/Methods/Approach:
Review of three studies conducted in different psychiatric settings in Slovenia.
Just a few mental health workers perceive their work as dangerous. Among those that are most frequently victims of violent behaviour are male and female nurses, especially under circumstances of involuntary admission, involuntary pharmacological treatment and when special security measures are applied. Participants think that workers would need more self defence trainings, additional competent medical staff (foremost male nurses), communication trainings and better cooperation in their working teams. Moreover, those hurt in such incidents should get more systematic help. Sometimes security personnel also intervene, however, they are not qualified for such interventions and special trainings should be provided.
Research limitations/implications:
Our findings have a limited value because the studies have been performed in the course of different years, different questionnaires were applied and participants also differed (their profession, working tasks, demographic data etc.). Practical implications:
Our findings can be used by psychiatric hospital management to plan trainings for mental health workers and organize them according to personnel's necessities. Results also imply the necessity to train security personnel. Originality/Value:
In the past merely analyses of incident reports were made on this topic. However, this paper sheds some light on perceptions and experiences of mental health workers directly exposed to patients' violent behaviour.
UDC: 616.89-052:343.62
Keywords: psychiatric setting, violent behaviour, mental health workers, safety, security personnel
Findings:
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Safety Issues in Psychiatric Settings
Občutek varnosti v psihiatričnih ustanovah
Namen prispevka:
V	prispevku želimo dognati, ali zdravstveno osebje v slovenskih psihiatričnih ustanovah zaznava svoje delo kot ogrožajoče in kateri dejavniki k temu največ prispevajo. Na osnovi pridobljenih podatkov so predlagane izboljšave občutka varnosti.
Metode:
Naredili smo pregled treh študij, opravljenih v različnih psihiatričnih ustanovah v Sloveniji. Ugotovitve:
Le manjši del zdravstvenega osebja (medicinske sestre, zdravstveni tehniki, zdravniki, klinični psihologi) zaznava svoje delo kot nevarno. Žrtve nasilnega vedenja psihiatričnih bolnikov so najpogosteje medicinske sestre in zdravstveni tehniki, predvsem ob sprejemu v bolnišnico proti volji, ob prisilnem zadrževanju oziroma oviranju in ob aplikaciji zdravil. Sodelujoči menijo, da bi potrebovali več usposabljanja s področja samoobrambe, dodatne kompetentne sodelavce, predvsem moškega spola, treninge komunikacije in boljše sodelovanje znotraj kolektiva. Poleg tega so mnenja, da bi zdravstveni delavci, ki so žrtve nasilnega vedenja bolnika, bili deležni sistematične pomoči. Občasno pri nasilnih dogodkih intervenira tudi varnostna služba, ki pa za tovrstne intervencije ni usposobljena, zato bi bilo potrebno organizirati posebna usposabljanja zanje. Omejitve/uporabnost raziskave:
Ugotovitve imajo omejeno vrednost, saj so bile raziskave izvedene v različnih letih, podatki so bili zbrani na različen način pa tudi vzorci zaposlenih se razlikujejo (izobrazba, delovne naloge, demografski podatki itd.). Izvirnost/pomembnost prispevka:
V	preteklosti so bile na tem področju izvedene le analize poročil nasilnih dogodkov. Prispevek osvetljuje izkušnje in občutke ogroženosti zdravstvenih delavcev, ki so neposredno izpostavljeni v tovrstnih incidentih.
UDK: 616.89-052:343.62
Ključne besede: psihiatrična ustanova, nasilno vedenje, zdravstveni delavci, varnost, ogroženost, varnostne službe
1 VIOLENCE AND MENTAL HEALTH
A patient's safety was long believed to be a priority within health care, while the health worker's security was not taken into account (Poster & Ryan, 1993). However, data on aggressive and/or violent incidents towards medical workers show high incidence of such behaviours and therefore put the profession of health workers among risk occupations (Pagon, Lobnikar, & Jereb, 2001). Cebasek Travnik (2009) also states that little is done to protect medical workers against frequent violent behaviour by their patients.
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There is increasing concern about the level of violence within mental healthcare settings. The relationship between mental disorder and violence is best summarized by Davison (2005). After reviewing epidemiological studies she concludes that people with mental disorders are more likely to be violent, especially if there is substance misuse, psychotic symptoms and/or comorbidity with personality disorder. However, gender, age, past violence and socio-economic status contribute more to the risk of violence, than merely the presence of a mental disorder and it is also important to emphasize that the vast majority of people with mental disorders are not violent.
Whittington (1994) states that the comprehension of acceptable and unacceptable behaviour of psychiatric in-patients changed. Violent behaviour was earlier considered unavoidable and taken as a professional risk, while nowadays it is regarded mostly as inadmissible. Nevertheless, mental health workers still view it as a part of their profession and are more tolerant of such behaviours than employees of other professions (Kores Plesnicar & Kodric Lasic, 2004). As already mentioned, the majority of mental health patients are not violent and just a few are involved in violent incidents. Serious harm as a consequence of such incidents is even rarer. The highest rate of violent behaviours is found in psychiatric intensive care units, forensic units and locked wards (Davison, 2005). Aggressive and violent behaviour is often a manifestation of a patient's defence against fears and distress experienced in different phases of the treating process. Feelings of fear can stem from patient's psychopathology, his or her ignorance about the treatment and consequently from distrust and because of external provocative incidents (Cosic, 1995).
Working with acutely disturbed people carries significant risk for health workers. Even though preventive measures are implemented, dangerous behaviour cannot always be avoided. In fact, it is present quite often and medical personnel are not trained during their regular education as to which measures to take in such cases (Mozgan, 2009).
1.1 Violence
One of the definitions distinguishes passive, verbal, physical and psychological violence (Živič, 2000). A passively violent patient rejects cooperation and is anxiously distant. Verbal violence includes aggressive expressions and offensive language, accompanied with corresponding gestures and facial expressions (Živič, 2000). A physically violent patient can assault and harm others by beating, slapping, spitting, pushing, kicking, choking, arm twisting etc. and such behaviour can be also object oriented (Klemenc & Pahor, 2004). Humiliation, threats and mocking are regarded as psychological violence (Božič, Uršič, Strojan, Ziherl, & Bučar, 1999).
Violent behaviour can be directed towards oneself, others and toward objects. Within the mental health settings violence toward others includes other patients and mental health staff. Studies show that medical personnel experiences more violence than other patients, however, differences in frequency are small (Whittington, 1994).	_
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2 IN-PATIENT VIOLENCE: RISK FACTORS
Categorisation of risk factors for violence encountered in the health care settings usually includes patient, personnel and environmental risk factors (Kores Plesnicar, 2006).
2.1 Patient Risk Factors
Among violent psychiatric in-patients the most commonly reported diagnosis is schizophrenia. Nevertheless, the fact that schizophrenia is also the commonest diagnosis in in-patient psychiatric settings should not be overlooked (Davison, 2005). Violent behaviour is mostly expected from patients with imperative hallucinations, paranoid thinking, personality disorders (paranoid, borderline, antisocial) and with demented, delirious or intoxicated patients (Davison, 2005; Groleger, 2009).
Age is also a potential risk factor. Younger patients (about 20 years old) are more dangerous, because health workers try to manage the situation by themselves and are consequently exposed to threats. Similarly incidents occur with older patients, in that case, however, it is because their physical strength is underestimated (Whittington, 1994).
Some authors report no consistent findings in regard to gender: research does not confirm that men are more violent than women (Whittington, 1994). Some studies actually show that women in hospital settings are involved in more violent incidents, but men are much more likely to cause injury (Davison, 2005).
Violent behaviour can be expected more frequently from patients that have a history of such behaviour, who overtly express their violent intentions or are weak in anger and impulse control (Groleger, 2009).
2.2 Environmental Risk Factors
The environmental factors above all include physical facilities with optimal ward layout and staff characteristics: their experience, training, number and clearly defined roles are some of the important contributors to (non)violence. Davison (2005) also emphasises ideal staffing ratio, optimal ward observation policy, role of prosecution policies, substance misuse policies and an optimal diagnostic mix of patients. Macpherson, Dix, and Morgan (2005) both stress that violence risk can be lowered by an ideal environment for a patient: ensuring privacy, options and independence.
Compulsory admissions also places a mentally disordered person at risk of becoming violent, next to restraining violent patients, implementation of therapy without the presence of the doctor and steady standards used in locked wards like restriction of smoking, movement and telephone use, determined time for rest and patient's boredom (Komazec, 2000).
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2.3 Personnel Risk Factors
Research found that staff's uncertainty of their roles, many substitute nursing staff and higher staff-patient ratio was related to increased violence. When staff members set limits, when nurses had less experience or staff did not have training in aggression control techniques, violence also rose (Owen, Tarantello, Jones, & Tennant, 1998). When patients feel safe and their activities are supervised by competent personnel, the risk for violence considerably decreases (Macpherson et al., 2005). Therefore provocative, weary and tired personnel with inappropriate communication can induce undesired behaviour (Davison, 2005).
3 PREVENTIVE AND SECURITY MEASURES 3.1 Prevention
Since the phenomenon of violence is to be expected in psychiatric settings, preventive measures should be taken. Prevention, however, must respect the law and human integrity and not violate human rights and privileges (Mozgan, 2009).
For psychiatric institutions security devices such as alarms, panic buttons, video surveillance of locked wards and metal detectors are recommended. Besides, an optimal staff ratio must be ensured and at the same time this assures help to every mental health worker whenever the need to manage a patient's violent behaviour arises (National Security Institute, 1995).
Moreover, all the personnel should be adequately trained and qualified to prevent and manage violent behaviour through relating, communicating and sometimes by using physical force (Poster & Ryan, 1993). One of the goals of the trainings could be early recognition of warning signs of violence (Owen et al., 1998) that enables early de-escalation (talking down) procedures that calm down the patient and deals with anger and frustration in a non-violent way (Davison, 2005). This technique requires calm intervention, using lower voice, slower speech, strictly avoiding provocation and giving orders. Calm talk and friendly persuasion decreases or even prevents violence (Andrejek Grabar, 2009). Enough personal space must be provided since a violent patient needs four times more personal space to not feel threatened. It is desired that only one person talks to the patient, one needs to be carefully listened to and he or she should be allowed to vent his or her emotions (Dernovsek, 2009; Andrejek Grabar, 2009; Robar, 2009).
3.2 Special Security Measures
In cases when the more collaborative approach fails and the situation becomes dangerous, steps must be taken to make staff, the patient and others safe.
Indications for using special security measures are divided into two subgroups: first group is intended to enable the patient's treatment and the second includes measures needed to manage dangerous behaviour (i.e. self-harming and/_
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or suicidal actions, threatening others). These measures violate human rights and must be thoroughly thought out (Dernovsek & Novak-Grubic, 2001).
Special security measures can be physical, chemical (Davison, 2005) or both. Patients in this cases prefer chemical interventions, talking and personal persuasion to physical restraint, because the latter is experienced as traumatic, inhuman and degrading (Dernovsek & Novak-Grubic, 2001). It is important to know that these measures are taken only after the psychiatrist's decision and are intended only to safeguard the personnel and the patient and never to punish the patient or mitigate the situation on the ward (Macpherson et. al., 2005; Groleger, 2009).
3.3 After the Incident
After every incident a formal report needs to be made and the procedure should be analysed. A study (Owen et al., 1998) shows, however, that this is rarely done, possibly because the staff treats violence as a part of psychiatric work or it merely finds administrative work redundant. Nevertheless, regulations require that after a violent incident a discussion about the causes, course, measures taken and consequences must take place. Moreover, special attention must be paid to mental health workers that were involved in the accident.
Mental health workers must often deal with potentially stressful situations (i.e. violent behaviour, nursing a violent patient, involuntary admission) that can trigger different emotional reactions: a person can be anxious about his or her own safety, or fear about ethical and legal consequences of violence. The professional identity can be shaken, dissatisfaction increases, so does absenteeism and the possibility of errors, while effectiveness decreases (Solc, 2001). Without proper support the personnel can develop the burnout symptoms and high fluctuation of staff is also common (Brennan, 1997).
4 METHODS
This is a review of three studies conducted in different psychiatric settings in Slovenia: The Begunje psychiatric hospital (Kolman, 2009), the Ljubljana psychiatric clinic (Simionov, 2009) and the Ormož psychiatric hospital Ormož (Vohar, 2011). The purpose of the review is to establish if mental health workers in Slovene psychiatric settings perceive their work as potentially dangerous and which factors contribute mostly to these mindsets.
4.1 Study in the Begunje Psychiatric Hospital (Kolman, 2009)
Nineteen female and seven male nurses took part in the study. Their average age was 39.8 years (min = 21 years, max = 55 years) and the average work experience of the group was 10 years.
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For this study a questionnaire of 25 questions was formed, 4 of them were open ended questions. The first part of the questionnaire regards demographic data, second part the frequency of violent assaults and the interventions used and the last part includes questions about preventive measures and how to improve them.
4.2 Study in the Ljubljana Psychiatric Clinic (Simionov, 2009)
Structured interviews were made with ten male nurses working in a locked ward. Their average age was 31.5 years (min = 24 years, max = 47 years) and the average work experience of the group was 10 years. The interview included questions about violence exposure at work, its frequency, safety measures taken before and during violent incidents and the nurses' perception of threat at work. Additionally, a review of violent incident reports from 2007, 2008 and 2009 was made.
4.3 Study in the Ormož Psychiatric Hospital (Vohar, 2011)
60 professionals in this mental health setting participated in the study: 9 doctors and 51 male and female nurses. 75% of the participants of participants were women. Their average age was forty years old (min = 21 years, max = 65 years) and most of the participants had more than 10 years of working experience.
A questionnaire of 32 questions was formed. Its first part regards demographic data; the second part regards factors influencing patient's violent behaviour, actions after the incidents and staff attitudes towards violence. The last part tries to identify current conditions in violent behaviour prevention and its improvement.
5 RESULTS
5.1 Study in the Begunje Psychiatric Hospital (Kolman, 2009)
Most of the nurses have experienced a physical assault by a patient, some of them repeatedly. Nurses understand these assaults above all as related to patients' mental disturbance and feelings of being threatened. The most common are assaults under circumstances of involuntary admission to the hospital and involuntary pharmacological treatment.
Nurses feel threatened only at times. Half of the participants estimated that after the incident help was not needed and consequently did not ask for any. Some took a few days of sick leave and a few needed medical attention, some also required psychological support.
More than a third of participants think that they lack the know-how of measures to be taken in cases of physical threat. The rest think that their knowledge is sufficient and that they handle critical incidents well. The majority of the_
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participants took a self defence class, course of aggression management, use of Segufix bands1 and other trainings.
The participants suggest the following improvements for a safer working environment:
-	repeated self defence courses,
-	more medical staff, especially male nurses,
-	more communication trainings,
-	psychological support and supervision,
-	a more appropriate selection of medical staff,
-	more attention to staff security and safety.
In spite of this data 80% of participants do not consider changing their employment.
An interview with a female and a male nurse was made. They share the belief that verbal and physical violence stem mostly from the patients' condition and that such incidents are an integral part of their work. Consequently incidents are not reported, even though they should be. They both agree that medical workers do not have enough training in preventing and managing violent behaviour. Co-workers discuss this topic, but mostly on an informal level and not systematically.
5.2 Study in Ljubljana Psychiatric Clinic (Simionov, 2009)
Far more violent incidents were registered on the reception ward for male patients (130 in years from 2006 to 2008) in comparison the same period on the female reception ward (104 cases). On the locked wards (female, mixed and geriatric) a considerably smaller number of incidents were reported: 139 altogether (from 2006 until 2008).
199 cases of patients' physical violence were directed at others, verbal violence was reported 122 times, auto aggressive acts in 85 cases and violence directed to objects 68 times. Escapes from locked wards were also registered: 20 in 2006, 11 in 2007 and 7 in 2008.
The study shows that a calming conversation was most often used as an intervention to a violent incident (432 times), pharmacological intervention was needed in 193 cases. Other staff members had to intervene 156 times and special security measures were applied 151 times. Violent incidents caused:
-	physical harm of the patient (90 times),
-	psychological consequences of the patient (209 times),
-	psychological consequences of staff (62 times),
-	physical harm of staff (53 times),
-	object damage (56 times).
Interviews made with male nurses working on locked and reception wards showed that all of them have been frequently victims of verbal and physical violence
_1 Segufix bands are a part of a Restraint and Positioning System of patients.
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of patients. Most often violent incidents occurred in cases of involuntary admission to the hospital, involuntary pharmacological treatment and when special security measures were needed. Being threatened by the patients is regarded as inescapable and violence at work is expected. However, safety conditions on the working place are seen as poor. Male nurses are aware of the threats they are exposed to and think that the management should provide a safer working environment. Nevertheless, these warnings are not taken into consideration.
5.3 Study in Ormož Psychiatric Hospital (Vohar, 2011)
The majority of participants (53, 88.33%) feel safe when working with psychiatric patients. Results of this study show that gender does not have an influence on the level of safety a person perceives. Those that do not feel safe (3 male and 4 female nurses, 11.67%) work on locked wards. Comparing them with the rest of the personnel nurses are most often in contact with the patients and are therefore often targets of their violent behaviour. About half of all participants are victims of physical assaults weekly or even daily, the other half reported having these experiences on a yearly basis. Number of assaults on the locked ward exceeds the number of assaults on other wards all together. After the incidents 6 persons (10%) needed medical help and 8 (13.33%) needed psychological support.
Patients behave most violently when they are admitted involuntarily, when special security measures are applied and when they get pharmacological treatment involuntarily. Mental health workers believe that high rates of patients with unpredictable behaviour, lack of medical staff, unsuitable communication by the staff and crowded wards are factors that increase the frequency of violent incidents.
More than 80% of mental health workers (50 workers, including doctors) believe they lack training in reacting when they are endangered - especially in situations when special security measures are used. More than 70% (44 medical workers) also think that additional trainings in de-escalation techniques are needed. Interestingly, 48 participants (80%) have not attended any trainings regarding prevention and managing violent behaviour in the last five years.
To increase staff's security medical workers have the following suggestions:
-	more staff, especially male,
-	trainings in preventing and managing patients' violent behaviour,
-	constant presence of security personnel,
-	self defence trainings.
6 COMMON FINDINGS OF THE STUDIES REVIEWED
Our findings are limited since the studies have been performed in the course of different years, different questionnaires were applied and participants also differed (their profession, working tasks, demographic data etc.). The following conclusions should therefore be discussed as assumptions with limited value:	_
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The majority of medical workers, especially nurses have experienced physical violence by a patient. Such incidents happen in reception and locked wards weekly, sometimes even daily. Physical assaults are mostly believed to be caused by the patients' condition and their anxiety.
Violent incidents mostly happen under circumstances of involuntary admission, involuntary pharmacological treatment and when special security measures are applied. A majority of incidents are registered. However, verbal aggression is rarely reported, even though it should also be done.
Just a few mental health workers perceive their work as dangerous and believe that their safety conditions could be improved. Patients' violence in all forms is expected and medical workers regard it as an integral part of their jobs.
A few nurses were hurt while managing violent patients; afterwards some required medical help, some psychological support and some took sick leave. Participants in the study think that workers hurt in such incidents should get more support that is systematic and not sporadic. Care offered to patients after violent outbursts has greatly improved and is much better that the support and care given to medical personnel.
Participants agree that they lack communication skills to prevent violent behaviour and perceive that they are not trained adequately to manage physical violence.
Mental health workers believe that in order to reduce the number of violent incidents and experience safer and more successful work they would need more self defence trainings, additional competent medical staff (male nurses above all), communication trainings and better cooperation in their working teams.
7 CONCLUSIONS
Research was conducted in three psychiatric hospitals with the intention to ascertain whether mental health workers feel threatened at work, to discover factors contributing to this perception, what needs to be changed to decrease patients' violent behaviour and identify more effective interventions that have less negative consequences for the patients and staff.
The review of research shows that the safety of mental health workers is not noted; even more so on reception and locked wards where the number of incidents is highest. Among other security measures like hiring additional male nurses, mental health workers would prefer constant presence of security personnel. This is already present and its tasks regarding the patients are limited to preventing escapes from the hospital and controlling the entry into the medical facility. Security personnel should not intervene when violent behaviour occurs since they are not qualified to handle such incidents. For this reason the security staff working in psychiatric settings should be educated in psychopathology and psychiatric disorders but most of all in handling violent psychiatric patients.
As already mentioned, personnel would need additional training (recognising warning signs, communication skills as violence prevention etc.) that would result _in a smaller number of violent incidents, but they should also be trained in special
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security measures to ensure less physical harm of patients and staff. If nurses would feel confident in mastering preventive techniques their interventions would be firm, professional, without hesitation whether ethical standards are violated and this would gradually lead to a reduction of violent outbursts. Group supervision is also an important part of such professions; it results in more professional and effective work, moreover it addresses ethical dilemmas and relieving potential psychological consequences of experiencing violent behaviour.
It is necessary to stress the importance of reporting every aggressive or violent incident. By doing so a more adequate care of the patient can be planned and in our opinion in some patients violent behaviour would decrease. Keeping records of such incidents would also enable more accurate analyses of motives regarding violent behaviour. Namely, this does not necessary stem from the patient's condition, but can also be a consequence of inadequate living conditions, organization of daily activities (e.g. not enough exercise, being included in activities), poor relations among patients or between patients and personnel.
Patients' safety must certainly be a priority in a psychiatric hospital, but care for staff's safety should not be overlooked. Uncaring attitude of the management can contribute to feelings of threat, which lead to dissatisfaction, disappointment, absenteeism, errors and in cases of violent behaviour avoiding interventions and/ or excessive use of force.
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About the Authors:
Tinkara Pavšič Mrevlje, MSc, Assistant lecturer of Psychology at the Faculty of Criminal Justice and Security, University of Maribor, Slovenia. E-mail: tinkara. pavsicmrevlje@fvv.uni-mb.si
Peter Umek, PhD, Professor of Forensic Psychology at the Faculty of Criminal Justice and Security, University of Maribor, Slovenia. E-mail: peter.umek@fvv.uni-mb.si
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