Management of inpatient aggression in forensic mental health nursing : the application of the Early Recognition Method

Abstract

Management of Inpatient Aggression in Forensic Mental Health Nursing. The application of the Early Recognition Method. Forensic mental health nurses take care of forensic patients convicted for an offense for which they were assessed not to be fully accountable due to their psychiatric disorder. For most forensic patients the core problem is to control their aggression. The Early Recognition Method [ERM] aims at providing nurses with a structured risk management strategy which enables them to interact with their patients in managing patients’ aggression. The concept early recognition is based upon the proposition that patient behavior deteriorating towards aggression is idiosyncratic but nevertheless reconstructable like a “signature.” Emphasis is on the detection of early warning signs, which can be defined as the perceptions, thoughts, and behaviors occurring prior to the occurrence of aggressive behavior. This thesis describes the concept of early recognition and how the ERM was applied and studied in a highly secured forensic hospital in The Netherlands. In the ERM intervention study the effects were explored of using ERM with forensic patients (n=168). The hypothesis was that patients who become involved in ERM will become less aggressive and therefore will undergo seclusion less often. Using a one-way case-crossover design, where cases were their own controls, the effects of ERM were assessed by comparing incidents during ‘Treatment As Usual’ with the period after ERM was implemented. A significant decrease in the number of seclusions was observed after ERM was introduced. The mean severity of inpatient incidents was also found to be lower during the post intervention period. The effect size was most pronounced for patients with substance abuse and personality disorders. Patients with schizophrenia showed modest, yet significant, effect sizes. Patients convicted of sexual offenses did not show significant improvement. The Forensic Early Signs of Aggression Inventory [FESAI] was developed aiming to support patients and nurses to collaboratively assess early warning signs of aggression in a structured way. A total of 3768 “early sign” phrases were studied by using both qualitative and quantitative research strategies, resulting in the FESAI containing 44 early warning signs of aggression subdivided into 15 categories. In the FESAI follow-up study early detection plans of 171 patients were studied which revealed 1478 early warning signs. Almost half of these signs fell within the categories Anger, frustration and/or tension, Social isolation, Decreased social contact and Changes of daily activities. The FESAI results of subgroup of patients showed considerable similarities in the ranking of early signs. Detached–concern of staff towards their patients was studied whether the application of ERM and the degree detachment or concern were interrelated. No significant relation was found, however, the sores of female nurses showed a tendency towards more concern after implementation of ERM. The results of the ERM intervention study suggest that ERM may be an innovative and effective risk management method for forensic psychiatric patients, in particular for patients with personality disorders. Follow-up studies with controlled designs, in patients who apply ERM for longer time and well into the rehabilitation phase are needed.