Violence in mental health care: the experiences of mental health nurses and psychiatrists

Violence against mental health service personnel is a serious workplace problem and one that appears to be increasing. This study aimed to ascertain the extent and nature of violence against mental health nurses and psychiatrists, and to identify what support, if any, they received following exposure to violence. Mental health staff working within five West Midlands Trusts in the United Kingdom were surveyed using a postal questionnaire to investigate the extent and nature of violence they encountered in their daily work. There was an overall response rate of 47%, which included a response rate for psychiatrists of 60% (n=74) and for mental health nurses of 45% (n=301). Though both groups experienced violence at work, nurses were found: to have been exposed to violence significantly more during their career; to have been a victim of violence within the previous 12 months of the survey; and to have suffered a violent incident involving physical contact. Whilst a higher proportion of nurses than psychiatrists received some support following a violent incident, a large proportion of both groups did not receive any, although most felt in need of it. The implications of this study for training and management are discussed.     

The work and values of mental health nurses observed

While there is agreement among stakeholders that change is required in mental healthcare, yet the precise nature of this change and how it should be brought about are relatively under-explored. Research has looked at developments taking place in primary mental health services, but relatively little has examined the work of community mental health nurses (CMHNs), especially those working at the interface between primary and secondary care. This study used a 39-item questionnaire to explore how CMHNs perceive their role and the degree to which they are able to carry it out. The findings suggests that while CMHNs are enthusiastic about their work and are keen to see mental health services develop in primary care, many are concerned about how they are perceived by other health personnel, deficiencies in their therapeutic skills and the level of support they currently receive. The study concludes by suggesting areas that managers, commissioners and educators should target to enable CMHNs to continue to play their part in a service that relies heavily upon them.     

Aggression and violence in health care professions

Although violence is increasing in most workplaces, it has become a significant problem in health care professions. Not only has the number of incidents increased but also the severity of the impact has caused profound traumatic effects on the primary, secondary and tertiary victims. More health care professionals than ever are suffering from symptoms of post-traumatic stress disorder.Addressing the problem of violence in the workplace has been exacerbated by a lack of a clear definition of what constitutes aggression and violence. As a result, some administrators have been slow to commit resources to prevent further incidents and mitigate the impact. This article describes the magnitude of the problem from both an academic research and an operational perspective. A definition is presented as an initial step towards standardizing the research, and establishing an appropriate baseline upon which intervention policies and procedures can be created. This benchmark will also help to encourage empirical research into aggression and violence in health care professions and other professions. Further research needs to be conducted to create a comprehensive instrument that can more accurately measure the range of incidents and the severity of the impact.     

急诊护士遭受工作场所暴力后心理状况调查分析

目的探讨急诊护士遭受工作场所暴力后的心理健康状况。方法应用症状自评量表（symptom checklist-90,SCL-90）对3所综合医院60名遭受过工作场所暴力后的急诊护士进行问卷调查,并将SCL-90各因子得分与国内常模进行比较。结果遭受工作场所暴力后,急诊护士在躯体化、强迫症状、抑郁、焦虑、敌对、恐怖、精神病性等方面的因子分及总分、总均分均高于常模,均P〈O．01或P〈0．0．5,差异具有统计学意义。结论遭受工作场所暴力后,急诊护士心理健康状况明显差于一般人群,应给予受暴者人文关怀,并采取措施预防和干预工作场所暴力和心理伤害的发生。     

Assault experiences: Lessons learned from mental health nurses in Taiwan

Mental health nurse are frequently subjected to patients' violent and aggressive behaviour. These assault experiences have given rise to mental health nurses' physical and psychological trauma, and negatively impact the quality of patient care. The purpose of the present qualitative study was to understand mental health nurses' experiences of being assaulted, the influences on their patient care, and their perspectives of the effectiveness of in‐service, violence‐prevention education. Ten mental health nurses from two different inpatient mental health facilities were interviewed using a semistructured interview guide. Thematic analysis of interview data found six themes: (i) violence is unpredictable; (ii) violence is normal; (iii) lasting psychological trauma; (iv) limited support from peers and the administrator; (v) violence prevention requires team cooperation; and (vi) doubting the effectiveness of in‐service education on violence prevention. Psychiatric ward administrators should assess nurses' learning and skill needs to determine whether these needs are met by existing in‐service training programmes. A culture of safety should also be promoted by building a warm and supportive ward climate for both staff and patients, which would include team cooperation and support for colleagues who suffer a violent incident.     

Occupational violence and assault in mental health nursing: a scoping project for a Victorian Mental Health Service

The present study aimed to examine the prevalence of occupational assault against nurses at a Victorian Mental Health Service, including inpatient units and community teams. The results of this study will assist in developing strategies to minimize the occurrence of occupational assault and, more importantly, its impact for nursing staff. A survey methodology was used. All nurses from two adult acute psychiatric inpatient units as well as those from the community-based teams were invited to participate in a single survey (n = 90). The sample group for this research included all nursing staff from both inpatient units and community services. High levels of occupational violence against nurses overall and in the past year, underreporting of incidents, and high levels of staff fear are prominent findings of this study. There needs to be a total review of all policy relating to occupational violence with special focus given to the results of this study. The areas of risk management, training, sanctioning, and incident reporting should head the list, as well as addressing staff culture. Universally adopting a zero tolerance approach to occupational violence suggests that it is far from being part of the job. Further, management should consider a comprehensive orientation package that informs patients and their significant others about the role of the treating team. Communicating adequately with patients and their significant others is needed to clarify expectations and to avoid frustration and angry outbursts.     

Common experiences of mental health nurses and consumers: Ingredients of a symbiotic relationship?

Examination of the history of consumers and mental health nurses reveals that both consumers and mental health nurses have much in common in terms of their powerlessness and their sense of being undervalued. This paper argues that their common problems have a shared solution. It is in the interest of both groups to develop a symbiotic relationship, with each other benefiting by achieving greater influence over the delivery of care. The development of a close alliance requires a change in perception and behaviour towards each other. This paper identifies some of the factors militating against developing a symbiotic relationship and suggests possible ways of addressing them.     

Smoking and mental health nurses: a survey of clinical staff in a psychiatric hospital

There is a lack of evidence on the prevalence of smoking among mental health nurses, and the beliefs and attitudes they hold about smoking at work. This paper describes results from a cross-sectional survey of clinical staff working in a UK specialist charitable-status psychiatric hospital and focuses on the responses of registered mental health nurses. Questionnaires specifically developed for this study were sent to all 1371 clinical employees. Completed questionnaires were returned by 167 of 429 (38.9%) registered nurses (RNs), 300 of 842 (35.6%) nursing assistants (NAs), and 123 of 200 (61.5%) other health professionals (OHPs). Twenty-nine (17.4%) RNs, 93 (31%) NAs and eight (6.5%) OHPs reported themselves as current smokers. Differences in response to attitudinal questions between groups could not be attributed to age. RN smokers were significantly more likely than RN non-smokers to state that staff should be allowed to smoke with patients, and to report therapeutic value for patients in this activity. RN smokers were less likely than RN non-smokers to report that patients should be encouraged to stop smoking. RNs were significantly more likely than OHPs to report therapeutic value for patients in smoking with staff, even after controlling for the possible confounding effect of smoking status. Implications of the survey are discussed in the context of the international literature, including the disproportionately high smoking prevalence among patients living in psychiatric institutions and current guidelines to move towards no 'smoking allowed' areas for staff working in them.     

护士职业应激与精神卫生状况分析

[目的 ]了解护士职业应激与精神卫生状况及其相关性。 [方法 ]应用抑郁自评量表(SDS)和焦虑自评量表 (SAS)及护士职业压力源量表对 779名在岗护士进行调查。 [结果 ]护士抑郁和焦虑发生率分别为3 6.3 %和 14 .2 % ,两者并存者占 11.6% ,SDS和SAS标准分均值与国内常模比较有统计学意义 (P <0 .0 1) ;护士职业应激总分 1.97分± 0 .460分 ;精神卫生与职业应激呈高度正相关 (P <0 .0 0 1)。 [结论 ]护士群体精神卫生状况低下 ,与其职业应激密切相关。管理者应在引导护士正确认识和舒缓职业应激的同时 ,考虑到女性的社会脆弱因素及其独特的生理特征     

Self-esteem in community mental health nurses: findings from the all-Wales stress study

The authors conducted an all-Wales survey of community mental health nurses (CMHNs) to determine their levels of stress, coping and burnout. A total of 301 CMHNs were surveyed in 10 NHS Trusts in Wales. A range of measures were used. These included the General Health Questionnaire (GHQ-12), Maslach Burnout Inventory (MBI), Rosenberg Self-Esteem Scale (SES), Community Psychiatric Nursing (CPN) Stress Questionnaire, and PsychNurse Methods of Coping Questionnaire. The findings from the Rosenberg SES are reported here. Community mental health nurses in Wales scored as having average self-esteem. When the data were divided into high and low self-esteem, a large group of CMHNs (40%) were found to have low self-esteem. Factors that are associated with low and high self-esteem were identified. Alcohol consumption and being on lower nursing grades (D, E, F) were associated with low self-esteem, whilst amount of experience working as a CMHN was associated with high self-esteem.     

A comparison of the work and values of community mental health nurses in two mental health NHS Trusts

With the reconfiguration of health services in both the primary and secondary sectors, the role of community mental health nurses (CMHNs) has become a highly contested one within mental health care. There would be great variability in the skills that CMHNs possess, the contexts in which they work and the nature of the work they do. This study sought to explore aspects of the work of those nurses who provide services at the interface between policy and practice. Two groups of CMHNs were compared, one working in an urban setting (Trust A) and the other in a rural (Trust B), focusing particularly on caseloads and client mix, the values held by CMHNs, the models of care they utilize and what they consider would improve care in the future. A specially designed 39-item questionnaire was employed, with a mix of open and closed questions, and statements to which participants were asked to respond on a three-point Likert scale. The findings raised interesting issues around collaborative working, whether CMHNs are happy to take on clients previously on their caseload, bureaucratization, autonomy, role definition within a culture of working with primary care, lack of specific models utilized by CMHNs, and the demand for greater training and educational support. The implications of the study are discussed with the aim of assisting mental health nurses determine their future roles.     

The role of the nurse prescriber: the views of mental health and non-mental health nurses

Even though the introduction of the role of the nurse prescriber promises improved access to medicines and increased flexibility in the workforce, the take-up of this role to date has been variable across the UK. This questionnaire-based study sought to compare the expectations of two distinct groups of nurses, one from a mental health and the other from a non-mental health background prior to becoming prescribers. Non-mental health nurses were of the opinion that being able to prescribe would increase efficiency and maximize resources, while mental health nurses saw prescribing primarily in terms of the benefits to clients--increased choice, improved access to care, better information about treatments and better quality of care.     

The content of management of violence policy documents in United Kingdom acute inpatient mental health services

AIM OF THE STUDY: The aim of the study was to examine the content of Trust policies concerning the prevention and management of violence in acute in-patient settings in order to establish their usefulness as guidance for staff in this difficult, complex, and controversial aspect of inpatient psychiatric care. BACKGROUND: Violence is a commonly encountered problem in inpatient psychiatric settings. There are legal requirements for workplaces in general and mental health care facilities in particular to develop safe systems of work based upon the findings of assessments of this risk. Policies have a key role to play in making explicit the responsibilities of both employer and employees, and specifying standards of acceptable practice. DESIGN: A cross-sectional survey methodology was used, which entailed examination of the content of management of violence policies that had been forwarded to the authors from 40 Trusts providing acute inpatient psychiatric care throughout England, Scotland, Wales, and Northern Ireland. FINDINGS: Policies were found to vary widely in their content, and serious shortcomings were noted in the extent to which policies included information regarding their status and review, advice on the prevention of violence, the management of violent incidents, and postincident action. CONCLUSIONS: Further research is needed to tease out the extent to policies which are lacking in content, reflect shortcomings in the organizational approach to the prevention and management of violence by Trusts, and the extent to which such shortcomings result in harm being suffered by staff and/or patients. An alternative format for the presentation of management of violence policies is discussed, and items that should be included in inpatient units' management of violence policies are suggested.     

Primary mental health workers in child and adolescent mental health services

BACKGROUND: The interface between primary care and specialist services is increasingly seen as crucial in the effective management of child and adolescent mental health (CAMH) problems. In the United Kingdom, a new role of primary mental health worker (PMHW), has been established in order to achieve effective collaboration across the interface through the provision of clinical care in primary care settings and by improving the skills and confidence of primary care staff. However, little is known about the development of this innovative role in service contexts. Issues raised during the early stages of implementation may have important implications for the preparation and development of professionals who undertake the role. AIMS: The aim of this paper is to report on a study that examined key issues in implementation of the PMHW role in six health authorities in England. METHODS: Case study evaluation was conducted, using thematic analysis of 75 qualitative interviews with key stakeholders from different professions (e.g. PMHWs, general practitioners, health visitors, psychiatrists and service managers) and representing different sectors (primary care, specialist services and community child health services). FINDINGS: The study identified three models of organization (outreach, primary care-based and teams). Each was associated with different advantages and disadvantages in its effects on referral rates to specialist services and the development of effective working relationships with primary care providers. Problems associated with accommodation and effective integration of PMHWs with specialist services, and tensions caused by the two different roles that PMHWs could undertake (direct clinical care vs. consultation-liaison) were common across all sites. CONCLUSIONS: The PMHW role is an important development that may go some way towards realizing the potential of primary care services in CAMH. The implementation of new roles and models of working in primary care is complex, but may be facilitated by effective planning with primary care providers, clear goals for staff, and a long-term perspective on service development.     

Collaboration between mental health consumers and nurses: shared understandings, dissimilar experiences

Adopting a collaborative approach within clinical relationships is illustrative of consumers' and nurses' positive beliefs, values, and attitudes towards each other and their partnership. However, for collaboration to be successful, how roles are determined, how each partner relates to the other, and how decisions are to be made need to be clearly defined and agreed upon. The research study described here utilized a mixed-method approach comprising focus groups and surveys to explore the subjective understandings, attitudes, and experiences of consumer-nurse collaboration within a mental health rehabilitation context in order to more clearly determine the conditions for successful nurse-consumer collaboration. The study found that although consumers and nurses conceptualized collaboration in similar ways, their lived experiences were disparate. A key finding of the study was that mutual recognition of each others' knowledge and expertise is needed for successful collaboration. The study reinforced the need for consumers and nurses to establish common ground on which to collaborate and to articulate the behaviours and expectations of working collaboratively. While collaboration was acknowledged as a significant and desirable basis for therapeutic relationships, it was challenged by determinants of power, such as knowledge, information, and expertise.     

Perceiving risk in dangerous situations: risks of violence among mental health inpatients

BACKGROUND: Violence in British psychiatric hospitals appears to be escalating, with nursing staff the most frequent victims of assault. There is also public concern about violence on the part of individuals with mental health problems. In this climate, assessing a patient's risk of violent behaviour has become an important part of mental health care. However, little research has been published into how mental health nurses undertake such assessments in their day-to-day clinical practice. AIM: The study focused on how mental health nurses make assessments of risk in clinical crisis situations where there is a perceived likelihood of imminent violence. The study sought to identify skills, cognitive processes or any other mechanisms which nurses draw upon to assist in such assessments. METHOD: Ten experienced mental health nurses working in a secure mental health environment were interviewed and data generated was analysed using a grounded theory approach. An in-depth literature search was also undertaken. FINDINGS: It was found that, in their risk assessments, nurses rely extensively on their personal knowledge of their patients (in particular, previous history of violent behaviour; biographical data; and impact of the mental health problem on violent behaviour). Nurses 'tune in' to potentially violent situations by observing a scenario as a whole, as well as specific aspects of a patient's behaviour, whilst also searching for causes of the violent behaviour. In making clinical risk assessments, nurses often make rapid, intuitive judgements in which various possibilities are considered regarding the likelihood of violent behaviour (such as the capacity and capability of a patient to be violent and the potential in the situation). It was also found that the ability to intervene successfully in potentially violent situations reduced the level of risk that nurses felt exposed to, and here nurses draw on their knowledge of a particular patient. They also perceive lower levels of risk when working in a skilled team. CONCLUSION: The study indicates that the development of nurse-patient relationships and working in a supportive team are perceived as protective factors against risk. Implications of the research are discussed in relation to nurse-patient relationships, particularly in the context of the current nursing climate and the way in which violent behaviour may lead to an erosion of these relationships. The importance of 'working in a team' is discussed, as is the consequence of the findings for education and development. Methodological limitations of the study are also discussed.     

综合干预对急诊科护士心理健康状况的影响

目的探讨综合干预对提高急诊科护士心理健康水平的效果。方法采取改善： 工作环境、规范抢救流程、实行责任组长负责制、学习法律法规、成立心理支持小组、运用激励机制等措施进行干预,在实施干预前后运用症状自评量表对38名急诊科护士进行测试。结果急诊科护士的心理健康状况较一般人群差,突出表现为躯体化、人际关系、抑郁、焦虑、恐怖和强迫;经综合干预后,能有效缓解心理压力。结论应重视急诊科护士心理健康状况,并给予相应干预,能有效地缓解急诊科护士的心理压力,提高其心理健康水平。     

'You don't talk about the voices': voice hearers and community mental health nurses talk about responding to voice hearing experiences

Aims and objectives. To explore service user and community mental health nurses views on responses to voice hearing experiences. Background. People who hear distressing auditory hallucinations (voices) are often in contact with mental health services. Nursing responses to this experience have been limited, although emerging evidence suggests some utilitarian alternative interventions, such as discussing the content and meaning of the voices. Design. Using exploratory interviews, this study investigated the response to voice hearing, with a purposive sample of community mental health nurses (n = 20) and service users (n = 20). This paper reports on a thematic content analysis of transcribed interviews, which highlighted differences in perspectives of voice hearers and the nurses supporting them. Results. Voice hearers reported that interventions from community mental health nurses were limited to reviews of medication, access to the psychiatrist and non‐directive counselling. They identified alternative needs, which involved talking more about the content and meaning of their voices. Conversely, community mental health nurses regarded their responses to voice hearing as being considered, titrated and demonstrating an awareness of the personal contexts of service users. These responses were however restricted by their perception of skill limitations. Conclusions. The contrasting views of nurses and users of services demonstrated in this study, reveal multiple social realities that represent a challenge to accepted professional responses in the provision of mental health care. Relevance to practice. People who hear voices express an interest in more helpful responses from community mental health nurses. The findings of this study indicate that nurses must begin to orientate themselves towards a more critical practice stance that encompasses available knowledge on the voice hearing experience.