School of Health Sciences, Division of Nursing, Midwifery and Social Work, Jean McFarlane Building, University of Manchester, Oxford Road, Manchester, M13 9PL, UK.
Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK.
BMC Psychol. 2022 Feb 15;10(1):30. doi: 10.1186/s40359-022-00735-6.
Violence and other harms that result from conflict in forensic inpatient mental health settings are an international problem. De-escalation approaches for reducing conflict are recommended, yet the evidence-base for their use is limited. For the first time, the present study uses implementation science and behaviour change approaches to identify the specific organisational and individual behaviour change targets for enhanced de-escalation in low and medium secure forensic inpatient settings. The primary objective of this study was to identify and describe individual professional, cultural and system-level barriers and enablers to the implementation of de-escalation in forensic mental health inpatient settings. The secondary objective was to identify the changes in capabilities, opportunities and motivations required to enhance de-escalation behaviours in these settings.
Qualitative design with data collection and analysis informed by the Theoretical Domains Framework (TDF). Two medium secure forensic mental health inpatient wards and one low secure mental health inpatient ward participated. 12 inpatients and 18 staff participated across five focus groups and one individual interview (at participant preference) guided by a semi-structured interview schedule informed by the TDF domains. Data were analysed via Framework Analysis, organised into the 14 TDF domains then coded inductively within each domain.
The capabilities required to enhance de-escalation comprised relationship-building, emotional regulation and improved understanding of patients. Staff opportunities for de-escalation are limited by shared beliefs within nursing teams stigmatising therapeutic intimacy in nurse-patient relationships and emotional vulnerability in staff. These beliefs may be modified by ward manager role-modelling. Increased opportunity for de-escalation may be created by increasing service user involvement in antipsychotic prescribing and modifications to the physical environment (sensory rooms and limiting restrictions on patient access to ward spaces). Staff motivation to engage in de-escalation may be increased through reducing perceptions of patient dangerousness via post-incident debriefing and advanced de-escalation planning.
Interventions to enhance de-escalation in forensic mental health settings should enhance ward staff's understanding of patients and modify beliefs about therapeutic boundaries which limit the quality of staff-patient relationships. The complex interactions within the capabilities-opportunities-motivation configuration our novel analysis generated, indicates that de-escalation behaviour is unlikely to be changed through knowledge and skills-based training alone. De-escalation training should be implemented with adjunct interventions targeting: collaborative antipsychotic prescribing; debriefing and de-escalation planning; modifications to the physical environment; and ward manager role-modelling of emotional vulnerability and therapeutic intimacy in nurse-patient relationships.
在法医住院精神卫生机构中，冲突导致的暴力和其他伤害是一个国际问题。已经推荐了降低冲突的缓和方法，但这些方法的证据基础有限。本研究首次使用实施科学和行为改变方法，确定了在低、中安全法医住院环境中增强缓和的具体组织和个人行为改变目标。本研究的主要目的是确定和描述在法医精神卫生住院环境中实施缓和的个人专业、文化和系统层面的障碍和促进因素。次要目的是确定在这些环境中增强缓和行为所需的能力、机会和动机的变化。
定性设计，数据收集和分析由理论领域框架（TDF）指导。两个中等安全的法医精神卫生住院病房和一个低安全的精神卫生住院病房参与了研究。根据 TDF 领域的半结构化访谈指南，通过五个焦点小组和一个个人访谈（根据参与者的偏好）共 18 名工作人员和 12 名住院患者参与了研究。数据通过框架分析进行分析，组织成 14 个 TDF 领域，然后在每个领域中进行归纳编码。
增强缓和所需的能力包括建立关系、情绪调节和提高对患者的理解。由于护理团队内部存在共同的信念，限制了护士-患者关系中的治疗亲密性和护理人员的情绪脆弱性，因此工作人员缓和的机会有限。这些信念可以通过病房经理的角色扮演来改变。通过增加服务使用者参与抗精神病药物的处方和修改物理环境（感官室和限制对病房空间的限制），可以为缓和创造更多机会。通过事后汇报和高级缓和计划减少对患者危险的看法，员工参与缓和的动机可能会增加。
在法医精神卫生机构中增强缓和的干预措施应增强病房工作人员对患者的理解，并改变对限制医患关系质量的治疗界限的信念。我们的新分析产生的能力-机会-动机配置的复杂相互作用表明，仅通过知识和技能培训不可能改变缓和行为。缓和培训应与以下附加干预措施一起实施：协作抗精神病药物处方；汇报和缓和计划；修改物理环境；病房经理在护士-患者关系中扮演情感脆弱性和治疗亲密性的角色。
