Strategies for reducing aggression in a forensic setting

Tessa Maguire

Forensicare

• International concern

• Impact:

-Injury

-stress

-morale/staff turnover/job satisfaction

-therapeutic climate

• Coercive interventions-restraint and seclusion

Factors influencing aggression in Forensic inpatient units

• Protect public, provide custody and treatment

• Reasons for admission.

• No single factor accounts for inpatient aggression-contextual factors (structural/organisational/interpersonal) as important as personal factors.

• Proactive rather than reactive approach

Challenges to reducing aggression in the forensic setting

• Characteristics of patients

-challenging behaviours

-behavioural issues

-Patient transfer

-dual diagnosis

• Prisoner culture

• Demand for activity or denial of request Maguire, Young & Martin (2012)

Opportunities for reducing aggression in a forensic setting

• Longer admissions

• Staff-patient ratio

• Risk assessment and management

• Confidence in managing aggression

Maguire, Young & Martin (2012)

Violence by patients in psychiatric settings is frequently associated with the quality of staff-

patient interactions.

What is limit setting?

• An intervention that decreases behaviour that may be seen as problematic

• Establishing the boundaries of what is, and what is not, acceptable behaviour in an attempt to work with patients to develop behaviours that are not considered to be disturbing, unsafe or destructive, and to engage the patient in further treatment

(Stuart & Perlin, 2005; Neale & Rosenheck, 2000).

• Are limits important?

• What are the consequences of no limits?

Limit setting theory

• Psychoanalytical theory

• Shift from original meaning

Nurses in the forensic setting may need to set limits to:

• Maintain boundaries • Address risk issues • Safety • Facilitate the therapeutic relationship • Provide opportunity for healthy behaviours to

develop

(Henry, 2010; Langley & Klopper, 2005; Lyon, 1970; McLean & Nathan, 2007)

Outcomes of limit setting

• Limits can facilitate a therapeutic relationship, reduce anxiety, decrease problematic behaviour.

• Limit setting may be associated with an increased occurrence of incidents that involve disturbed or violent behaviour (NICE, 2005).

• Numerous studies have reported a link between limit setting and aggression (Davis, 1991; Roper & Anderson, 1991; Sheridan, Henrion, Robinson & Baxter, 1990).

Outcomes of limit setting

• 10-year prospective study of aggression in a Norwegian secure hospital 1564-recorded episodes of aggressive behaviour, 64% were triggered by situations related to limit setting (Bjørkly, 1999)

• Study examining staff and patients’ views of inpatient aggression found that patients considered a ‘controlling style’ by staff before and after episodes of aggression to be an important contributor to inpatient aggression (Duxbury, 2002).

Research method

• Limited research on limit setting

• Forensicare-Thomas Embling Hospital, 116 beds acute-continuing care

• Semi structured interviews: Patients and Nurses

• Thematic analysis

Tessa Maguire

Clinical Nurse Consultant

Post Graduate Program and M4 Coordinator

Affiliate Monash University

Victorian Institute of Forensic Mental Health

Locked Bag 10, Fairfield, Vic 3078

Tel (613) 94959165