SummaryNinety-six psychiatric wards from 42 English mental health services participated in an audit of the management of violence in adult in-patient settings. The audit programme began in February 1999 and ended in March 2000. The standards were drawn from the Royal College of Psychiatrists' clinical practice guidelines, which identified the factors that reduce the frequency of violence and minimise injury to staff and service users. The audit data included questionnaire returns from 3,609 people who worked on, used or visited psychiatric wards. Many aspects of the physical and social environment of the wards, staffing and communication systems fell short of the audit standards. The audit provided a baseline against which improvements in services can be gauged.
Key National FindingsThe physical environment
- Conditions of the wards: many wards failed to meet basic standards for a decent working or residential care environment. Wards were often rated as noisy, hot, dirty and smelly. Perhaps surprisingly staff were much less likely to report satisfaction with the physical environment of their wards than the users who were cared for there.
- Safety of design: although the layout of wards was considered to be an important influence on safety, less than 10% of wards were satisfied that sight lines allowed people to see what was happening on different parts of the ward.
Deprivation was a key theme that emerged.
- Privacy e.g. 14% of service users did not agree that they had privacy using the toilet.
- Dignity e.g. when asked whether they had felt able to maintain their dignity during their stay, 16% of service users said no.
- Protection: although one-third of service users and visitors reported that they had experienced violence on the ward, 72% reported that they had not been given advice on what to do and 47% that they did not know how to summon help.
- Access to staff time e.g. just 44% of service users agreed that staff had been around to talk to them if they were upset; 25% said that this had not been the case.
- Activity: only about one-third of service users reported satisfaction with daytime leisure and therapeutic activities, respectively; in relation to evening activities, the figure was just one-fifth.
- Information to service users: e.g. less than half of service users reported satisfaction with the information they had been given about what was wrong with them (over 1/3 said 'no')
- Communication systems e.g. 38% of staff agreed there was multi-disciplinary team consensus on care; just one-third agreed that channels of communication between staff and management were open.
- Access to training: 34% of staff had not, in the past 5 years, had any training that was directly related to the management of violence.
- Quantity: this ranged from 1.31 - 14.37 days per member of staff.
- Content of nursing training: 61.9% related to C&R, 15.5% to breakaway training, and 2.25% to de-escalation.
- Content of training for other staff: more likely to relate to breakaway i.e. 42.6% (clinical staff) and 51.8% (non-clinical).
- Adequacy of training: just less than one-half felt their training had equipped them to either prevent or manage violence.
- Access to supervision: 52% of staff reported they were receiving regular supervision.
- Reporting of incidents: although 61% of trusts had an agreed definition of violence, just 27% stated that all professional groups were signed up to this definition; just one-half of trusts reported that staff were inducted in the use of the reporting procedure.
- De-briefing: there was huge national variation in practice meaning that lessons were not always learned.
- Interface with police and the Crown Prosecution Service: although pockets of good collaborative working were evident, there was unacceptable national variation.
- Just over half of non-staff and two-thirds of staff (i.e. services users and visitors) agreed that violence between patients was managed effectively.
- 20% of non-staff felt the threat of using medication was used to control behaviour, compared with 4% of staff.
- Existing psychiatric wards should be improved so that they conform as closely as possible to the environmental factors in the guideline. New wards should be designed with these in mind.
- Performance management of mental health, services including the work of the Commission for Health Improvement, should include consideration of the extent to which wards are "safe".
- There should be national guidance about the content, length and frequency of training and refresher training, for all staff who work in places where violence is known to occur.
- There should be a nationally agreed framework describing links and procedures that should exist between MH services and the police and CPS. This should inform local protocols.
- Mental health services should develop coherent strategies for dealing with the aftermath of violent incidents. These should take account of the needs of service users as well as staff.
- There should be regular audit of violent incidents. This should review staffing levels/skills mix when the incident occurred.
- Local multi-disciplinary teams should develop and monitor strategies for the prevention and management of violent incidents.
DiscussionThe clinical practice guidelines on the management of violence was an ambitious project which drew together different types of evidence to produce useful guidance for clinicians. It represents best current knowledge about the factors that can minimise risk in relation to ward violence. The national audit is aimed to determine the extent to which good practice prevailed, to raise awareness of the guideline recommendations and to provide national data from which the audit findings highlight the areas in which practice of provision can be improved. For example, the guidelines suggest that the incidence of violence would be reduced if patients were engaged in meaningful occupation. However, only a third of the service users who participated in the survey were satisfied with the daytime leisure and therapeutic activities. Similarly, service users were dissatisfied with the accessibility of staff. Again, the guidelines suggest that addressing this problem would reduce the number of violent incidents.
Other key themes that emerge from the audit findings include: poorly designed physical environments that tend to be noisy, smelly and unclean; staff training that was perceived as being inadequate, poor communication between ward staff and managers.
It would be too easy to say that the answer to this problem lies in building new wards. This would not be sufficient. Firstly, many of the problems identified by the audit relate not to the wards themselves but to the social environment and to the training, support and deployment of staff. There is a danger that trusts would merely be moving these problems, and a less that ideal ward culture, to a new environment. Secondly, many of the issues highlighted can be addressed now and relatively inexpensively. Fir example, recognising the ward routine, increasing the amount of time nurses spend talking to service users, and changing the ways that the space on the ward is used does not cost money or require a new ward.
The trusts that took part in the audit programme have been encouraged to develop action plans to address specific local problems that were identified. The audit will only have been a success if these local plans are put into effect.
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