Review and Proposed Management of Violence in the Secure Psychiatric Ward_ Crimson Publishers

Review and Proposed Management of Violence in the Secure Psychiatric Ward by Ahmed SY* in Examines in Physical Medicine and Rehabilitation: Open Access_ Journal of Rehabilitation Medicine

Abstract
Anger, hostility, aggression and violence are commonly encountered in the secure psychiatric wards. These acts interfere with the therapeutic milieu and cause unrest amongst both staff and patients. Understanding the aetiology and variables associated with these are critical to establishing safer wards. In this review article we amalgamate and summarize findings from research within the last ten years. We use evidence from recent research, clinical guidelines and our individual experiences to describe how simple interventions may help in reducing the incidence in locked wards.

Introduction
Anger, hostility, aggression and violence are all interlinked, whilst commonly encountered within inpatient psychiatric environments. Escalation and difficulty in containing the above, normally leads to referral to services which offer greater levels of security (i.e. relational, environmental and procedural security). The Epidemiology Catchment Area study found that incidents of violence were five times higher in subjects with psychiatric illness [1]. There is some evidence from birth cohorts to suggest that there is a greater risk of violence amongst subjects with serious mental illness, in particular those with a diagnosis of Schizophrenia, when compared to the general population; this, however, remains a much debated, controversial finding [2]. It is therefore imperative to recognize and acknowledge these acts and the potential repercussions.

The goal of the inpatient setting is to provide a safe environment to aid the pathway to recovery. The therapeutic milieu is, however, very much unsettled by disturbing behaviors which place both the aggressor and other patients/staff at risk. The effect of these behaviors is extensive; from previous work, we are aware of the psychological impact of this on nursing staff [3] Dealing with these troubled behaviors on a daily basis can contribute to burnout in staff [3]. Our aim is to review the current research in the aetiology and variables associated with anger and hostility, which in turn drives aggression in these settings; our focus remains on the secure (PICU and Forensic) wards. There appear similarities in the antecedents which lead to violence by patients who are admitted to the wards, regardless of their psychiatric diagnosis. We will discuss briefly how this can be prevented with particular emphasis on the beneficial effects of changing the ward structure, organization and design.

To aid our review a literature search was conducted on articles produced in the last ten years around the aetiology of anger/hostility and violence. Our search yielded three sets of guidelines from NICE which included short term management, and the prevalence of violence/aggressive behaviors in those with a mental health diagnosis. We found two systematic reviews which focused on aggression in psychiatric wards and three research articles investigating the aetiology.

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