Search

The Dynamic Appraisal of Situational Aggression: Youth Version (DASA:YV) is a brief instrument, most often used by nurses and was specifically designed to assess risk of imminent violence in youth settings. To date, it has been recommended that DASA:YV scores are interpreted in a linear manner, with high scores indicating a greater level of risk and therefore need more assertive and immediate intervention. This study re-analyses an existing data set using contemporary robust data analytic procedures to examine the predictive validity of the DASA:YV, and to determine appropriate risk bands. Mixed effect logistic regression models were used to determine whether the DASA:YV predicted aggression when the observations are correlated. Two approaches were employed to identify and test novel DASA:YV risk bands, where (1) three risk bands as previously generated for the adult DASA were used as a starting point to consider recategorising the DASA:YV into three risk bands, and (2) using a decision tree analysis method known as Chi-square automated interaction detection to produce risk bands. There was no statistically significant difference between a four and three category of risk band. AUC values were 0.85 for the four- and three-category options. A three-category approach is recommended for the DASA:YV. The new risk bands may assist nursing staff by providing more accurate categorisation of risk state. Identification of escalation in risk state may prompt early intervention, which may also prevent reliance on the use of restrictive practices when young people are at risk of acting aggressively., (© 2024 The Author(s). International Journal of Mental Health Nursing published by John Wiley & Sons Australia, Ltd.)

Recovery-oriented practice is essential in healthcare, yet research exploring methods for integrating recovery-oriented principles in forensic mental health settings is limited. This study involved the co-development, with mental health care nurses and a lived experience expert, and testing of a recovery-oriented script for forensic mental health nurses to use when communicating with consumers at high-risk of imminent aggression. The aim was to examine whether nurses perceived the script as more empathic when the script included specific references to empathy, compared to an equivalent script that did not include empathic statements, and to explore nurses' perspectives on whether the script could help prevent aggression. Nurses (n = 54) working in a secure forensic mental health hospital were randomly allocated to read a script containing statements representing nine recovery-oriented principles that also included empathic statements, or an equivalent script that did not include empathic statements. After reading the script, the participants completed a questionnaire involving a recovery-oriented practice scale developed by the authors, measuring the extent to which the scripts reflected recovery-oriented principles, and open-ended questions about the script's potential to prevent aggression. Results revealed no significant difference in nurse perceptions of empathy between the two scripts. Content analysis indicated that nurses perceived the scripts could help prevent aggression., (© 2024 The Authors. International Journal of Mental Health Nursing published by John Wiley & Sons Australia, Ltd.)

Forensic mental health nursing is a specialty area of practice requiring specific knowledge and skills to work collaboratively with consumers. The Clinical Reasoning Cycle has been recognised as a potential framework to support nursing practice; however, it has been identified that adaptations are required to enhance utility in a forensic mental health services. The aim of this study was to explore and finalise a version of the cycle for forensic mental health nursing practice. Focus groups and interviews were used to explore adaptations with staff from a state-wide forensic service and forensic mental health nursing academics. Data were thematically analysed. Four main themes were interpreted: (1) allegiance to the Nursing Process, (2) moving the cycle from page to practice, (3) working as a team, or not, and (4) implementation will be a marathon and not a sprint. While nursing academics were more in favour of updating the Nursing Process to ensure contemporary practice is captured, staff from the service were supportive of the adapted cycle but emphasised the need to ensure collaboration with the consumer and their supporters. The adapted cycle was seen to articulate the contribution of forensic mental health nursing care, and support for a nursing-specific cycle was embraced by other disciplines, despite some hesitation from nurses. Prior to implementation there is a need to ensure the merits of the cycle are clearly articulated, along with a range of resources and specific contextual information to ensure the cycle can be successfully applied to enhance nursing practice and consumer care., (© 2023 The Authors. International Journal of Mental Health Nursing published by John Wiley & Sons Australia, Ltd.)

Forensic mental health (FMH) inpatient settings are complex working environments at times due to a number of factors including the presence of challenging behaviours that may include violence and aggression, restrictions related to legislation, extended length of stay and the impact of trauma. Nurse unit managers (NUMs) play an important role in managing the unit environment and clinical standards of care to achieve better outcomes for consumers and staff. However, the role of NUMs in an FMH setting is poorly understood. The overall aim of this study was to explore the role of NUMs working within an FMH setting in Victoria, Australia. To our knowledge, this is the first study that has examined the subject. Data were collected via focus groups from n = 32 participants which included NUMs, their managers, staff who work alongside the NUMs and the staff the NUMs manage. Data were analysed using thematic analysis and four themes were interpreted from the data, (i) lack of role clarity, (ii) the importance of clinical Leadership and forensic mental health knowledge, (iii) step up in responsibility and step down in pay and (iv) seeing the difference you make. The role of the NUM within a forensic mental health setting comes with a number of challenges, but also opportunities to enact change. An ongoing effort to better support those employed within the NUM role and make the role desirable for aspiring staff is critical to the sustainability of a skilled clinical workforce and quality of care in this complex setting., (© 2023 The Authors. International Journal of Mental Health Nursing published by John Wiley & Sons Australia, Ltd.)

Forensic mental health nurses (FMHN) provide care to address the needs of people who have mental illnesses across a range of diverse settings. The Clinical Reasoning Cycle (CRC) has been identified as a potential framework to assist FMHNs; however, adaptations were required to reflect the unique nature of the clinical setting. This study aimed to explore adaptations made to determine suitability prior to implementation in practice. Nominal Group Technique was used to explore suggested adaptations determined from a previous study and reach a consensus on the changes. Fourteen senior nurses from a state-wide Forensic mental Health (FMH) service participated. A consensus was reached for two proposed changes. Data were analysed using thematic analysis. Three main themes were interpreted from the data; FMH adaptations are warranted, the focus of the CRC, and who owns the cycle? Nurses in this study considered the need to include offence and risk issues due to the impact these factors have on the therapeutic relationship and cognitive bias; however, they also identified the need to focus on recovery-oriented care while engaging in clinical reasoning. Nurses in this study also expressed some reluctance for nursing to 'own' the model, due to concern that ownership may cause division among the team or result in inconsistency in care. However, some participant's suggested the CRC with adaptations assisted FMH nurses to articulate their specialist skills and knowledge to others and highlight the nursing contribution to care. Further work is needed to finalize adaptations with a focus on engaging the consumer carer workforce and interdisciplinary team., (© 2022 The Authors. International Journal of Mental Health Nursing published by John Wiley & Sons Australia, Ltd.)

The Nominal Group Technique is a method used to explore issues, generate ideas, and reach consensus on a topic. The Nominal Group Technique includes individual and group work and is designed to ensure participants have the same opportunity to engage and provide their opinions. While the technique has been used for around six decades to assist groups, in industry, and government organizations to examine issues and make decisions, this technique has received limited attention in nursing research, particularly in mental health. This discussion paper describes the use of a modified Nominal Group Technique for a study designed to determine a nursing decision-making framework for a state-wide forensic mental health service. Modifications were made to the traditional technique, to enable participants to make an informed and collective decision about a suitable framework for the novice to expert nurses, across secure inpatient, prison, and community forensic mental health settings. The Nominal Group Technique generated rich data and offered a structured approach to the process. We argue that the Nominal Group Technique offers an exciting and interactive method for nursing research and can increase opportunity for minority group members to participate. This technique also offers a time efficient way to engage busy clinical nurses to participate in research, with the advantage of members knowing the decision on the day of the group. Consideration, however, needs to be given to the duration and effect on participant concentration, and if not actively managed by facilitators, the possible emergence of group dynamics affecting individuals' decisions., (© 2022 The Authors. International Journal of Mental Health Nursing published by John Wiley & Sons Australia, Ltd.)

Forensic mental health nursing (FMHN) is a specialized field, designed to meet the needs of people who have a serious mental illness across the criminal justice system, inpatient services and community. Frameworks can assist assessment, planning, intervention, documentation and evaluation of nursing care. However, there is no prior research investigating frameworks in FMHN. This study aimed to explore the Nursing Process (NP) and the Clinical Reasoning Cycle (CRC), with nurses, to determine a suitable framework for use service-wide. A Nominal Group Technique was used to facilitate exploration of the two frameworks, where open-ended verbal and written responses collected from a Nominal Group were thematically analysed, and the participants voted on their preferred framework. Seventeen nurses from a state-wide forensic mental health (FMH) service participated. The four main themes were as follows: challenges to current practice, limitations of the NP, perceived benefits of the CRC and addressing implementation. Consensus was reached with the nurses selecting the CRC as the framework of choice. This is the first study to explore frameworks to guide practice in FMHN. Nurses in this study considered the CRC to be a suitable framework for novice through to expert, offering a contemporary framework to guide nursing care in complex FMH settings. Some adjustments to the existing cycle were suggested to emphasize recovery-oriented practice, and inclusion of family and carers. Any changes to the cycle warrant exploration with the interdisciplinary team and consumer carer workforce., (© 2021 John Wiley & Sons Australia, Ltd.)

Risk assessment is a pre-requisite for violence prevention in mental health settings. Extant research concerning risk assessment and nursing intervention is limited and has focused on the predictive validity of various risk assessment approaches and instruments, with few attempts to elucidate and test interventions that might prevent aggression, and reduce reliance on coercive interventions. The integration of risk assessment and violence prevention strategies has been neglected. The aim of this feasibility study was to test a novel Aggression Prevention Protocol designed to prioritize the instigation of less restrictive interventions on an acute forensic mental health unit for female patients. A prospective quasi-experimental study was designed to test an Aggression Prevention Protocol, linked to an electronic application of the Dynamic Appraisal of Situational Aggression (DASA). Following introduction of the DASA and Aggression Prevention Protocol, there were reductions in verbal aggression, administration of Pro Re Nata medication, the rate of seclusion, and physical and mechanical restraint. There was also an increase in documented nursing interventions. Overall, these results support further testing of the electronic application of the DASA and the Aggression Prevention Protocol., (© 2019 Australian College of Mental Health Nurses Inc.)

Seclusion and mechanical restraint are restrictive interventions that should be used only as a last resort and for the shortest possible time, yet little is known about duration of use in the broader context. Adult area mental health services throughout Victoria, Australia, were asked to complete a report form for prolonged episodes of seclusion (>8 hours) and mechanical restraint (>1 hour). The present, retrospective cohort study aimed to understand the individual (age, sex, type of service, duration of intervention) and contextual factors associated with prolonged use of restrictive interventions. Contextual factors describing the reasons for prolonged use of the restrictive interventions were captured qualitatively, and then coded using content analysis. Median duration was compared across individual factors using Mann-Whitney U-tests. During 2014, 690 episodes of prolonged restrictive intervention involving 311 consumers were reported. Close to half (n = 320, 46%) involved mechanical restraint. Seclusion episodes (n = 370) were longer in forensic mental health services compared to adult area mental health services (median: 24 hours and 18 min vs 16 hours and 42 min, P < 0.001). Mechanical restraint episodes (n = 320) were shorter in forensic mental health services compared to adult area mental health services (median: 3 hours and 25 min vs 4 hours and 15 min, P = 0.008). Some consumers were subject to multiple episodes of prolonged seclusion (55/206, 27%) and/or prolonged mechanical restraint (31/131, 24%). The most commonly occurring contextual factor for prolonged restrictive interventions was 'risk of harm to others'. Means for reducing the use of prolonged restrictive interventions are discussed in light of the findings., (© 2017 Australian College of Mental Health Nurses Inc.)

In the present study, we explored the predictive validity of the Dynamic Appraisal of Situational Aggression (DASA) assessment tool in male (n = 30) and female (n = 30) patients admitted to the acute units of a forensic mental health hospital. We also tested the psychometric properties of the original DASA bands and novel risk bands. The first 60 days of each patient's file was reviewed to identify daily DASA scores and subsequent risk-related nursing interventions and aggressive behaviour within the following 24 hours. Risk assessments, followed by documented nursing interventions, were removed to preserve the integrity of the risk-assessment analysis. Receiver-operator characteristics were used to test the predictive accuracy of the DASA, and generalized estimating equations (GEE) were used to account for repeated risk assessments, which occurs when analysing short-term risk-assessment data. The results revealed modest predictive validity for males and females. GEE analyses suggested the need to adjust the DASA risk bands to the following (with associated odds ratios (OR) for aggressive behaviour): 0 = low risk; 1, 2, 3 = moderate-risk OR, 4.70 (95% confidence interval (CI): 2.84-7.80); and 4, 5, 6, 7 = high-risk OR, 16.13 (95% CI: 9.71-26.78). The adjusted DASA risk bands could assist nurses by prompting violence-prevention interventions when the level of risk is elevated., (© 2017 Australian College of Mental Health Nurses Inc.)

The aim of the present study was to describe incidences of restrictive interventions and the association of methamphetamine use at an acute adult inpatient mental health unit in metropolitan Melbourne, Victoria, Australia. A total of 232 consecutive consumer admissions to the inpatient unit across a 3-month period were described for illicit substance use and the use of restrictive interventions (seclusion, mechanical restraint, and physical restraint) prior to and during admission. Of all admissions, 25 (10.8%) involved consumers subjected to a restrictive intervention. Methamphetamine use was either self-reported or detected by saliva test for 71 (30.6%) consumers. Following multivariate analyses, methamphetamine use (odds ratio (OR): 7.83, 95% confidence interval (CI): 2.33-26.31) and restrictive intervention in the emergency department prior to admission (OR: 8.85, 95% CI: 2.83-27.70) were significant independent predictors of the use of restrictive interventions after inpatient admission. Anecdotal observations provided by clinical mental health staff that consumers intoxicated with methamphetamine appear to require restrictive intervention more frequently than other consumers was confirmed with the results of the current study. As the state of Victoria in Australia is on a pathway to the elimination of the use of restrictive interventions in mental health services, clinicians need to develop management strategies that provide specialist mental health care using the least-restrictive interventions. Although 26.8% of methamphetamine users were secluded after admission, restrictive interventions should not be the default management strategy for consumers who present with self-report or positive screen for methamphetamine use., (© 2016 Australian College of Mental Health Nurses Inc.)

Limit setting is an intervention that is frequently used by mental health nurses. However, limit setting is poorly conceptualized, its purpose is unclear, and there are few evidence-based guidelines to assist nurses to set limits in a safe and effective manner. What is known is that the manner in which nurses set limits influences patients' perceptions of the interactions and their emotional and behavioural responses. In this qualitative study, 12 nurses and 12 patients participated in personal, semistructured interviews that aimed to explore limit setting and to propose principles to guide practice. The findings suggested that: (i) limit setting is important to safety in mental health hospitals; (ii) engaging patients in an empathic manner is necessary when setting limits (when nurses engage in an empathic manner, the therapeutic relationship is more likely to be preserved and the risk of aggressive responses is reduced); and (iii) an authoritative (fair, respectful, consistent, and knowledgeable), rather than authoritarian (controlling and indifferent), limit-setting style enhances positive outcomes with regards to adherence, reduced likelihood of aggression, and preservation of the therapeutic relationship. In conclusion, a limit-setting style characterized by empathic responding and an authoritative, rather than authoritarian interpersonal, style is recommended. Elucidating the components of this style is critical for effective training and best practice of mental health nurses, and to reduce aggressive responses from limit setting., (© 2013 Australian College of Mental Health Nurses Inc.)