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Culture and Ideology

In order for an inpatient unit to promote recovery, it is necessary to create a culture where staff feel safe and where patients feel safe and respected. A culture that is based solely on rules and procedures to minimize risks may have the effect of making patients feel inferior and making care less individualized than it needs to be to promote growth in an individual person. A rigid adherence to risk management strategies, while well-intended, may have the effect of psychologically harming the person that the rules are intended to physically protect. Use of trauma informed care and collaborative decision making can help nurses to engage patients in realizing recovery goals. Additionally, increasing staff ability to actively listen to patients and to manage their own stress levels can be effective in decreasing safety risks on units.

Trauma informed Care
Substance Abuse and Mental Health Services Administration. Trauma-Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. HHS Publication No. (SMA) 13-4801. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.

Shared decision making

Baby, M., Gale, C., & Swain, N. (2018). Communication skills training in the management of patient aggression and violence in healthcare. Aggression and Violent Behavior, 39, 67-82. doi:

“Challenging behaviours may sabotage therapeutic relationships if not addressed appropriately. While medication, environmental planning and staffing resources are requisites for the management of challenging behaviour, effective communication is an important aspect in the management of these challenging behaviours including aggression. Good communication helps the patient become an active partner in the process. Staff training that focuses on communication skills can be useful to both patients and healthcare workers. This paper aims to review the research evidence from existing communication skills training programmes that are exclusively or partly focused on the reduction of aggression perpetrated by patients. This review included one randomized controlled trial protocol, one quasi experimental study, six pre-test/post-test designs, three mixed methods, four qualitative studies, one descriptive survey and four with other designs that were mostly conducted in mental health settings. The findings show that communication skills training improve the confidence of staff in dealing with aggression. However, minimal number of studies with a focus on aggression reduction, the quality of the studies in terms of design and lack of active controlled trials minimizes the generalizability of the findings. These findings reiterate the need for future research with a focus on well designed, active controlled studies to establish the effectiveness of communication skills training as a suitable strategy to minimize and prevent patient aggression.”

Bryson, S. A., Gauvin, E., Jamieson, A., Rathgeber, M., Faulkner-Gibson, L., Bell, S., . . . Burke, S. (2017). What are effective strategies for implementing trauma-informed care in youth inpatient psychiatric and residential treatment settings? A realist systematic review. International journal of mental health systems, 11(1), 1-16.

“Background: Many young people who receive psychiatric care in inpatient or residential settings in North America have experienced various forms of emotional trauma. Moreover, these settings can exacerbate trauma sequelae. Common practices, such as seclusion and restraint, put young people at risk of retraumatization, development of comorbid psychopathology, injury, and even death. In response, psychiatric and residential facilities have embraced trauma‑informed care (TIC), an organizational change strategy which aligns service delivery with treatment principles and discrete interventions designed to reduce rates of retraumatization through responsive and non‑coercive staff client interactions. After more than two decades, a number of TIC frameworks and approaches have shown favorable results. Largely unexamined, however, are the features that lead to successful implementation of TIC, especially in child and adolescent inpatient psychiatric and residential settings. Methods: Using methods proposed by Pawson et al. (J Health Serv Res Policy 10:21–34, 2005), we conducted a modified five‑stage realist systematic review of peer‑reviewed TIC literature. We rigorously searched ten electronic databases for peer reviewed publications appearing between 2000 and 2015 linking terms “trauma‑informed” and “child*” or “youth,” plus “inpatient” or “residential” plus “psych*” or “mental.” After screening 693 unique abstracts, we selected 13 articles which described TIC interventions in youth psychiatric or residential settings. We designed a theoretically‑based evaluative framework using the active implementation cycles of the National Implementation Research Network (NIRN) to discern which foci were associated with effective TIC implementation. Excluded were statewide mental health initiatives and TIC implementations in outpatient mental health, child welfare, and education settings. Interventions examined included: Attachment, Self‑Regulation, and Competency Framework; Six Core Strategies; Collaborative Problem Solving; Sanctuary Model; Risking Connection; and the Fairy Tale Model. Results: Five factors were instrumental in implementing trauma informed care across a spectrum of initiatives: senior leadership commitment, sufficient staff support, amplifying the voices of patients and families, aligning policy and programming with trauma informed principles, and using data to help motivate change. Conclusions: Reduction or elimination of coercive measures may be achieved by explicitly targeting specific coercive measures or by implementing broader therapeutic models. Additional research is needed to evaluate the efficacy of both approaches.”

Hallman, I. S., O’Connor, N., Hasenau, S., & Brady, S. (2014). Improving the Culture of Safety on a High-Acuity Inpatient Child/Adolescent Psychiatric Unit by Mindfulness-Based Stress Reduction Training of Staff. Journal of Child and Adolescent Psychiatric Nursing, 27(4), 183-189. doi:10.1111/jcap.12091

“PROBLEM: The purpose of this study was to reduce perceived levels of interprofessional staff stress and to improve patient and staff safety by implementing a brief mindfulness-based stress reduction (MBSR) training program on a high acuity psychiatric inpatient unit. METHODS: A one-group repeated measure design was utilized to measure the impact of the (MBSR) training program on staff stress and safety immediately post training and at 2 months. Two instruments were utilized in the study: the Toronto Mindfulness Scale and the Perceived Stress Scale. FINDINGS: The MBSR program reduced staff stress across the 2-month post training period and increased staff mindfulness immediately following the brief training period of 8 days, and across the 2-month post-training period. A trend toward positive impact on patient and staff safety was also seen in a decreased number of staff call-ins, decreased need for 1:1 staffing episodes, and decreased restraint use 2months following the training period. CONCLUSIONS: A brief MBSR training program offered to an interprofessional staff of a high-acuity inpatient adolescent psychiatric unit was effective in decreasing their stress, increasing their mindfulness, and improving staff and patient safety.”

Hamrin, V., Iennaco, J., & Olsen, D. (2009). A Review of Ecological Factors Affecting Inpatient Psychiatric Unit Violence: Implications for Relational and Unit Cultural Improvements. Issues Ment Health Nurs, 30(4), 214-226. doi:10.1080/01612840802701083

“This review examines the research on ecologic factors that may contribute to or lessen the likelihood of inpatient unit violence. Understanding these factors can provide psychiatric inpatient unit staff with valuable therapeutic relational and cultural strategies to decrease violence. International and US studies from OVID Medline, CINAHL, and PsycInfo that evaluated aggression and violence on psychiatric inpatient units between 1983 and 2008 were included in this review. The review revealed that violence results from the complex interactions among the patient, staff, and culture of the specific unit. Inpatient psychiatric staff can decrease the potential for violence by using therapeutic relationship strategies such as using good communication skills, advocating for clients, being available, having strong clinical assessment skills, providing patient education, and collaborating with patients in treatment planning. Cultural improvements include providing meaningful patient activities and appropriate levels of stimulation and unit staffing.”

Manna, M. M. (2010). Effectiveness of formal observation in inpatient psychiatry in preventing adverse outcomes: the state of the science. J Psychiatr Ment Health Nurs, 17(3), 268-273.

“Formal observation in psychiatric settings is a widely accepted intervention employed by psychiatric nurses to reduce the incidence of adverse patient outcomes such as suicides, self-harm, violence and elopements in the psychiatric population. Formal observation includes general or routine observation, observation every 15 or 30 min, continuous or constant observation, and one-to-one observation. While formal observation consumes nursing resources, the efficacy of formal observation in reducing patient risk and providing therapeutic benefit remains unclear. To date, no randomized controlled studies exist. The existing qualitative research fails to demonstrate a direct correlation between the act of formal observation and the prevention of adverse patient outcomes. Common in the literature is a debate as to whether formal observation or therapeutic engagement is more beneficial. This paper, therefore, identifies gaps in the research and synthesizes relevant research regarding the effectiveness of formal observation in preventing adverse outcomes like suicides, self-harm, violence and elopements.”

Marcus, S. C., Hermann, R. C., Frankel, M. R., & Cullen, S. W. (2018). Safety of Psychiatric Inpatients at the Veterans Health Administration. Psychiatr Serv, 69(2), 204-210. doi:10.1176/

“Objective: Although reducing adverse events and medical errors has become a central focus of the U.S. health care system over the past two decades both within and outside the Veterans Health Administration (VHA) hospital systems, patients treated in psychiatric units of acute care general hospitals have been excluded from major research in this field.
Methods: The study included a random sample of 40 psychiatric units from medical centers in the national VHA system. Standardized abstraction tools were used to assess the electronic health records from 8,005 hospitalizations. Medical record administrators screened the records for the presence of ten specific types of patient safety events, which, when present, were evaluated by physician reviewers to assess whether the event was the result of an error, whether it caused harm, and whether it was preventable.
Results: Approximately one in five patients experienced a patient safety event. The most frequently occurring events were medication errors (which include delayed and missed doses) (17.2%), followed by adverse drug events (4.1%), falls (2.8%), and assault (1.0%). Most patient safety events (94.9%) resulted in little harm or no harm, and more than half (56.6%) of the events were deemed preventable.
Conclusions: Although patient safety events in VHA psychiatric inpatient units were relatively common, a great majority of these events resulted in little or no patient harm. Nevertheless, many were preventable, and the study provides data with which to target future initiatives that may improve the safety of this vulnerable patient population.”

Morgan C. Shields, Hailey Reneau, Sasha M. Albert, Leeann Siegel & Nhi-Ha Trinh (2018) Harms to Consumers of Inpatient Psychiatric Facilities in the United States: An Analysis of News Articles, Issues in Mental Health Nursing, 39:9, 757-763, DOI: 10.1080/01612840.2018.1451579

“Inpatient psychiatric facilities in the United States lack systematic regulation and monitoring of a variety of patient safety concerns. We conducted a qualitative analysis of 61 news articles to identify common causes and types of harms within inpatient psychiatric facilities, with a focus on physical harm. The news articles reported on patient self-harm, patient-patient violence, and violence between patients and staff, noting that youth, older adults, and veterans were especially vulnerable. Harms occurred throughout the care continuum—at admission, during the inpatient stay, and at discharge—and retaliation towards whistleblowers deterred facility accountability. We recommend 1) addressing staffing shortages, 2) instituting systematic monitoring of critical incidents and the experiences of consumers and staff, 3) improving both inpatient safety and post-discharge community supports, and 4) continued journalistic coverage of harms within inpatient psychiatric facilities.”

Muir‐Cochrane, E., Oster, C., Grotto, J., Gerace, A., & Jones, J. (2013). The inpatient psychiatric unit as both a safe and unsafe place: Implications for absconding. International Journal of Mental Health Nursing, 22(4), 304-312.

“Absconding from acute psychiatric inpatient units is a significant issue with serious social, economic, and emotional costs. A qualitative study was undertaken to explore the experiences of people (n = 12) who had been held involuntarily under the local mental health act in an Australian inpatient psychiatric unit, and who had absconded (or attempted to abscond) during this time. The aim of the study was to explore why people abscond from psychiatric inpatient units, drawing on published work from health geography on the significance of the person–place encounter, and in particular the concept of ‘therapeutic landscapes’. The findings show that the inpatient unit is perceived as a safe or unsafe place, dependent on the dialectical relationship between the physical, individual, social, and symbolic aspects of the unit. Consumers absconded when the unit was perceived as unsafe. Forming a therapeutic relationship with staff, familiarity with the unit, a comfortable environment, and positive experiences with other consumers all supported perceptions that the unit was safe, decreasing the likelihood of absconding. Findings extend existing work on the person–place encounter within psychiatric inpatient units, and bring new knowledge about the reasons why consumers abscond. Implications for practice are discussed.”

Slemon, A., et al. (2017). “Safety in psychiatric inpatient care: The impact of risk management culture on mental health nursing practice.” Nursing inquiry 24(4): e12199.

“The discourse of safety has informed the care of individuals with mental illness through institutionalization and into modern psychiatric nursing practices. Confinement arose from safety: out of both societal stigma and fear for public safety, as well as benevolently paternalistic aims to protect individuals from self- harm. In this paper, we argue that within current psychiatric inpatient environments, safety is maintained as the predominant value, and risk management is the cornerstone of nursing care. Practices that accord with this value are legitimized and perpetuated through the safety discourse, despite evidence refuting their efficacy, and patient perspectives demonstrating harm. To illustrate this growing concern in mental health nursing care, we provide four exemplars of risk management strategies utilized in psychiatric inpatient settings: close observations, seclusion, door locking and defensive nursing practice. The use of these strategies demonstrates the necessity to shift perspectives on safety and risk in nursing care. We suggest that to re- centre meaningful support and treatment of clients, nurses should provide individualized, flexible care that incorporates safety measures while also fundamentally re- evaluating the risk management culture that gives rise to and legitimizes harmful practices.”