Introduction
Violence and aggression negatively impact patients and health care professionals’ physical, emotional, psychological, and spiritual health both inside and outside a psychiatric setting. The majority of health care workers report cases of violence from psychiatric inpatients. A small percentage of patients causes violent acts, yet they are significant to the lives of the patient, other patients, and healthcare professionals. Health care staffs need to conduct violence assessments of each patient before adopting aggression management techniques. There are various management strategies used to contain these patients from their incivility towards nurses. However, some health care professionals prefer physical restraint techniques. This has led patients and various human rights activists to advocate for stopping the restraining methods and adopt alternative approaches to manage violent and aggressive psychiatric patients. The guiding principles for these strategies are summarized as the Six Core Strategies of the National Registry of Effective Programs and Practice 2012. There is a need to pay attention to alternative management strategies such as de-escalation for containing aggression and violence in inpatient psychiatric patient settings. These strategies focus on prevention, minimizing, and resolving the violence once they occur.
Alternative Management Strategies in Inpatient Psychiatric Patient Settings
Adopting a de-escalation technique in managing aggression and violence is a fundamental approach in a mental health setting. It is the preferred first-line intervention in managing these cases (National Institute for Health and Care Excellence, 2015). Verbal de-escalation consists of ten domains: respecting patients’ and personal space and maintaining a safe position, avoiding provoking the patient, establishing verbal contact, ensuring they send concise messages during conversations, and agree or disagreeing respectfully with the patients (Gaynes et al., 2016). Additionally, it consists of: polite negotiations by ensuring staff listen carefully to the patients, creating boundaries according to the law, allow them to make choices and enhance optimism, be an active listener and demonstrate it by verbal acknowledgment, conversation, and body language, and identify their feelings, wants and needs. Some patients have emphasized the need for de-escalation techniques and offered advice on their preferred approach for containing aggression (Caldwell et al., 2014). A successful verbal de-escalation technique requires the health care provider to verbally engage the patients, establish a collaborative relationship, and then verbally de-escalate them. This encourages the patients to follow the given directives.
The verbal de-escalation technique is only applicable to patients who can be in a dialogue with the psychiatry health care providers and cooperate in assessing and managing their agitation, aggression, and violence. However, in cases where the patient poses a risk to others and themselves, restraint can be used (Al-Awawde, 2014). This policy was enacted in India under the Mental Health Act 2017. Even though de-escalation techniques are preferred by most healthcare staff in a psychiatric setting, knowledge of this technique in real-life scenarios is limited (Berring et al., 2016). Health care workers need to create awareness of this technique to encourage widespread adoption. Concurrently, it is difficult to prove the success of this technique in reducing violence cases in psychiatric settings (Al-Awawde, 2014). Another systematic review identified that the evidence quality of this technique is low, making it inappropriate to drive conclusive results. More research studies are needed to analyze the success of this technique.
Psychiatry health care workers can adopt risk assessment techniques to prevent aggression and violence in inpatient psychiatric institutions. Risk assessment is a technique is recommended for use to reduce the use of seclusion and restrictive techniques (Fernández-Costa et al., 2020). This technique is an efficient alternative for restrictive methods because it identifies risk for violence and patients likely to exhibit aggressive behavior. It determines patients’ triggers and allows the health care staff to establish the necessary preventive measures (O’Rourke et al., 2018). Additionally, it is widely accepted as a universal trauma assessment tool in psychiatric institutions because it reduces the probability of patients agitating and escalating to aggressive actions (Fernández-Costa et al., 2020). This is enabled by identifying a patient’s threats to life and providing immediate treatment to avoid future triggers of aggression and violence. A study reported reduced cases of aggression and violence and restraint in studies that conducted risk assessment methods to contain the violence in psychiatric health institutions (Fernández-Costa et al., 2020). However, the systematic review identifies low strength of evidence in these studies. This calls for more research studies to provide evidence on this technique.
Multimodal interventions involving physical activities, changing patients’ diet, and cognitive training are essential in managing these patients. Some studies have attributed a significant reduction in the preference for restriction techniques when these techniques are adopted (Fernández-Costa et al., 2020). However, some studies analyzed the strength of evidence of these techniques and determined that limited research data is available to describe the guiding principles of this technique (Kane et al., 2017). Therefore, more scientific evidence-based studies need to be conducted to fill this gap.
Another effective strategy in managing aggression and violence in an inpatient psychiatric setting is involving the patients’ families, youths, and close relatives. This method is beneficial both to children and adults in an inpatient psychiatric setting. Patient involvement in their health care has resulted in a significant reduction in violence and the preference for restrictive techniques in psychiatric hospitals (Fernández-Costa et al., 2020). However, it is challenging to involve the patient in their care plan negotiations (Al-Awawde, 2014). Parents and close relatives can hold sessions to review the management methods and assist in developing a suitable treatment plan. Additionally, they can be involved in adopting other less restrictive strategies in managing the patient’s crisis and be an active contributor. These have been shown to reduce the adoption of restriction measures. Adopting open visitation hours in inpatient psychiatric settings has shown to be effective in preventing the use of restrictive measures (Caldwell et al., 2014). This is because they actively participate in activities with the staff and patients. Patients show a reduced rate of aggression and violence due to the home-like environment they create during their visits.
Sensory modulation programs have been used in calming down agitated, aggressive, and violent psychiatric patients instead of restrictive techniques. A systematic review study found a positive relationship between this program and a reduction in the use of restrictive practices (Fernández-Costa et al., 2020). Some studies attributed the success of sensory modulation in reducing to ensuring continued patient care and therapeutic instructions (Fernández-Costa et al., 2020). Some of the sensory modulation programs include creating an enabling environment for the patients by organizing sensory modulation activities to enhance their responsiveness to sensory information appropriately through active engagement in their daily activities. These programs aim at controlling the patients’ climate and minimizing external stimuli.
The behavioral characteristics of psychiatry health care staff play a significant role in the patients’ health. Psychiatry hospitals can adopt assessed behavioral competencies of the health care staff technique because it provides information about the factor trigging aggression and violence among patients (Raveesh et al., 2019). Additionally, these techniques help manage patients’ aggression and violent behaviors because the trigger has been identified and understood. Further, staffing increases the staff to patient engagement and interaction time (Gaynes et al., 2016). This reduces the need for restraining techniques in the management of psychiatric patients.
Trauma-informed care helps recognize the patient’s behaviors and responses as a direct relation to the traumatic experiences associated with a patient’s health concerns. Research studies have reported success in psychiatric hospitals that have adopted simple therapeutic patient-centered trauma-informed-care techniques to enhance the patient relationship with health care staff (Bryson et al., 2017). Adopting these techniques reduced the need to use restraint measures because they help reduce the patients’ intrinsic factors causing aggression and violence (Duxbury et al., 2019). Some of the programs involved in this technique include recovery-oriented programs and psychosocial or behavioral therapies (Bryson et al., 2017). These techniques improve the patients’ attitude towards staff and the hospital environment fostering civility (Pelto-Piri et al., 2020). This results in the reduced prevalence of violence and aggression in mental health care settings.
The adoption of psychosocial therapies enhances the relationship between the hospitalized psychiatric patients. A research study determined that psychiatric patients included in these therapies were well tolerated, their behaviors improved in the short and medium-term, and the incidences of violent outbursts reduced (Fernández-Costa et al., 2020). Some of the psychosocial therapies used are animal-assisted therapies, can-assisted therapies, and skills group psychotherapy (Fernández-Costa et al., 2020). These have assisted in significantly reducing aggressive behaviors among psychiatric patients. Animal-assisted therapy has shown significant success in reducing violent incidence among most patients. Adopting these techniques helps prevent and reduce the need for restrictive methods in the management of these conditions.
Training and education on these techniques are essential aspects in managing a violent situation in a mental health institution. Training assists in improving the staff’s competence in these techniques and enhances their knowledge of suitable ways of adopting less restrictive practices to strengthen their efforts in psychiatric patient management (Pelto-Piri et al., 2020). Additionally, education and training allow staff and patients to collaborate to decide on effective techniques in managing aggression (Duxbury et al., 2019). This helps avoid unnecessary conflict that might arise between them due to insufficient understanding or respect for boundaries. Moreover, training and education aim to develop the health care professionals’ attitudes and behaviors towards psychiatric patients (Duxbury et al., 2019). Studies have found that some incidences of violence towards staff are due to inappropriate attitudes and behaviors towards psychiatric patients (Duxbury et al., 2019). Education and training enhance the professionals’ emotional self-management before and after violent incidents to minimize their urge to use restrictive techniques in psychiatric patient care.
These techniques vary in their success, and most are dependent on one another. A study found that mental health hospitals in Finland enhanced these techniques through collaborations with other interdisciplinary health care professionals and persons in authority (Raveesh et al., 2019). These improved the patients’ cooperation to treatment and participation in their care. It is recommended for health care staff to adopt these techniques according to the patients’ condition. Concurrently, the adoption of pastoral care after a violent event helps enhance the staff’s attitude towards the profession and assist the patient in recovery, and preventing the triggers of violence and aggression in the future (Leavey et al., 2017). When handling more aggressive patients, restraint-fading can be used by limiting the duration of restrain. In the past, behavioral analysts have used restraint fading on patients with developmental disabilities (Raveesh et al., 2019). This technique is used in managing and reducing self-harm behaviors among these patients. Therefore, it eliminates the need for restrictive strategies for managing psychiatric patients.
Conclusion
In conclusion, these strategies focus on prevention through de-escalation, risk assessment, multimodal interventions, the inclusion of patients, family, and relatives in treatment and management, sensory modulation, and assessment of staffs’ behavioral competencies. Additionally, they focus on minimizing and resolving violence and aggression by adopting simple therapeutic patient-centered trauma-informed care. These intervention strategies enhance the patient and staff environment and have shown to be effective in minimizing patient violence and aggression in psychiatric health care institutions. This is because they create a cooperative relationship between staff and patients. Moreover, these strategies improve the patients’ health and allow them to be part of their care. Health care professionals need to be trained on violence management techniques and be flexible in utilizing them to ensure success in psychiatric patient management. These management techniques have varying success in the management of violence and aggression in inpatient psychiatric settings. Finally, there is a need for more studies to provide more data on the success of these techniques in the management of aggressive and violent patients in inpatient psychiatric settings.
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