The occurrence of violent incidents decreased substantially on this forensic high security ward in the middle phase of the 17 years of observation. Changes in 10 care- and organizational variables took place during this decline phase. The increasing level of an overall factor, composed of the 10 variables, coincided with this decline in the rate of violence. Seven of 10 care- and organizational variables were significantly associated with violence levels, but due to collinearity, their relative impact could not be assessed. We will argue that the increase in the overall factor, strongly associated to the declining violence rate, relates to a shift towards individualized patient-oriented care. The care- and organizational variables may have affected this change process to varying degrees.
An important intervention may have been the shared staff and patient review after violent incidents (reflecting upon both staff and patients’ perspectives), which was implemented early in the declining trend in violent incidents. A similar procedure is recommended in NICE guidelines [40]. This routine may contribute to improved understanding of warning signals and precipitations and may have the potential to influence staff-patient interactions and relations. Positive relationships with staff is highlighted as essential for personal recovery in forensic patients in several studies [41,42,43]. Forensic patients report that feeling safe and understood, and to have trust in staff is a crucial part of their recovery [41, 43].
Among nursing staff characteristics, the increased proportion of female staff may have played an important role. The proportion of female staff increased in a couple of years parallel to reduced violence rate. Corresponding findings are reported in previous studies [14, 44]. Explanations suggested were same-sex aggression [44] and that use of male nursing staff to control violence may represent a self- fulfilling prophecy [14]. The increase in health-educated staff also seems to be an important factor in our study. However, the literature presents inconsistent findings in this topic [41] and further investigation of the importance of such a variable is needed.
Restrictions and loss of freedom, leading to every-day frustrations, may increase violence risk [45]. Opportunities for unescorted leave, increasing patient autonomy, reduced use of sedating antipsychotic medication and implementation of new legislation, increasing in patients’ rights, may have contributed to less perceived coercion. These variables were related to the level of violence, but in the case of unescorted leave, the link was not significant. This finding is interesting, as unescorted leave would seem as a measure of freedom and one might expect the opposite finding. However, from these findings, it seems more important to have less restrictions inside the ward, as well as increased patient rights in their treatment, to reduce violent incidents. Furthermore, escorted leave may also have enhanced connectedness and support from staff. Connectedness is emphasized as one of the essential recovery processes for patients with mental illness [46].
Patient turnover rate increased during the period. Higher violence risk is found among newly hospitalized patients [47], but our finding may suggest more ambitious and encouraging treatment and discharge plans, and thereby increased experience of being able to move forward in life. Implementation of multi-disciplinary treatment plans and treatment meetings may have reinforced this trend.
Some variables, contrary to expectations about possible impact upon violence rate, had a weak and non-significant relation. Violence risk assessment procedures could be expected to contribute to violence prevention [18]. Nursing staff were however not actively involved in such measures the first years following implementation. The importance of varied activities and meaningful life is emphasised in other studies [20], but the mandatory patient activity program was not related to violence rate. This was, however introduced as a group measure, rather than an opportunity for the individual patient, and the provocative aspects of this measure may have contributed to raise levels of conflict.
None of the individual patient characteristic examined, except unstable personality disorder, were related to violence. Patients with this diagnosis are overrepresented in forensic settings, and linked to high rates of aggression [48]. However, this variable cannot explain the violence decline, as the proportion of patients with unstable personality disorder did not change during the study period.
The overall care- and organizational factor overlaps with the wide range of contextual violence-related variables described in literature-reviews [6,7,8]. Additional aspects of the ward context, as staff-patient relations in risk and violence management are however also addressed. A possible impact of common staff and patient review after violent incidents, intended to take care of the aggressor-victim relation and to facilitate problem solving is not found in literature. The marked increase in the proportion of women in the nursing staff, previously rejected for security reasons, may also have contributed to risk management less dependent upon the use of force and thereby less provocative. This may have contributed to relational alternatives to the prevailing force-based approaches, tempting to use in difficult situations.
Safety-building practices, as cooperation about risk management, are found in wards with low levels of violence [16, 49]. Studies based upon patient and staff views also emphasise relations and individualized aspects of risk management in forensic settings. Relationships are highlighted as a fundamental part of recovery trajectories [41], therapeutic alliances are seen as crucial in risk assessment, providing personal information about the patient and contributing to inclusion and participation [50] and encouraging patient participation is considered important in avoiding and preventing violence [51].
Emphasis upon patient perspectives and cooperation is particularly interesting considering the recent recovery-approach in forensic psychiatry [52], promoting patient responsibility, shared decision making and self-determination [53]. There are similarities between the described ward change process and domains of recovery-oriented violence prevention strategies. Although not directly influenced by the recovery philosophy, the ward change which underlies this study may have common sources in the prevailing professional discussions toward the end of the twentieth century.
Strengths and limitations
For reasons such as the discontinuity of nursing staff, a lack of reliable data and unstable clinical and administrative conditions, there is a shortage of long-term clinical studies on the impact of contextual factors. Such studies can be complicated by a limited time span, natural fluctuations in violence rates within institutions, the delayed effects of interventions or limited control of internal and external conditions. All these factors may weaken the validity and generalizability of outcomes.
In this study, a long series of reliable incident data, relevant clinical information and historical sources is available. Change in important ward characteristics in an otherwise stable setting provides features of a quasi-experimental design. The present study, examining the impact of care- and organizational variables upon inpatient violence, addresses the call for knowledge about the impact of contextual factors.
A rival hypothesis to the impact of a care and organizational factor, not examined in this study is that patients admitted later in the study period were less violent than the original patients were. In addition, the temporal clustering of change in care variables also limits the possibility of drawing strong conclusions about causality. The dissimilar form of the variables also excludes direct comparison of variables. Data sources are also limited. The sample of care- and organizational variables could have been more comprehensive, for example about organization and leadership [9, 25], the social climate [49] or the quality of staff-patient interaction or aggression management skills [54]. Some of the variables may be weakly related to central aspects of individualized patient-oriented care. To test the rival hypothesis of change in patient characteristics more exhaustively, we would have needed additional patient data, e.g., individual dynamic, fluctuating risk data, or data about patients before admittance and quality of preceding services delivered to the patients.
Implications
The importance of the dimension of individualized care-orientation may contribute to the understanding of institutional violence and give some clues about intervention strategies. In addition to situational risk factors of institutional violence included in instruments such as Promoting Risk Intervention by Situational Management (PRISM) [55], this study address protective factors, such as patient perspective, staff-patient cooperation and thereby promoting more confident staff-patient relations.
The study’s findings are relevant with regard to further adaptation of the recovery-oriented limitations of this study. Care- and organizational variables must be included in larger controlled studies with a longitudinal design. Knowledge about contextual impact upon violence in clinical settings is requested, but also challenging due to the large range of potential environmentally confounding and dynamic variables. This study highlights the importance of an individual-oriented care dimension of such variables as well as the importance of mixed gender staffing and educational level of the nursing staff members. This pattern appeared after examining a multifaceted change process. Useful knowledge can be gained by studying long term change patterns in ward settings. Relevant clinical and milieu data is useful for the testing of short-term hypotheses as well as clinical decision making. Access to such variables may facilitate and inspire further case-studies based on a diversity of sources and methods [56, 57].