Summary
Ninety-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 Findings
The 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.
Social environment
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.
Communication
- 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.
Staff training, development and
supervision
- 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.
Institutional responses to violent
incidents
- 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.
The management of violence
- 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.
Key Recommendations
- 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.
Discussion
The 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. For
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.