It seemed to happen with a predictable regularity.
“Nora” was an inpatient diagnosed with a personality disorder at New Hampshire Hospital (NHH), a psychiatric hospital providing acute services for children and adults under the New Hampshire State Department of Health and Human Services. At a certain time of day, Nora began to decompensate, becoming restless, aggressive, and threatening to harm herself. Ultimately, she required seclusion or restraint.
“We called staff together for a case conference to look at the pattern of behavior that led to the decompensation and think about ways to get the patient motivated at that period of day and involved in certain activities, or to get her off the unit if that was necessary,” said Alexander de Nesnera, M.D., associate medical director at NHH and an associate professor of psychiatry at Dartmouth University’s Geisel School of Medicine.
“A decision was made to have two staff members accompany her away from the inpatient unit and to the hospital gym,” he said. “By intervening in this way, we could break the cycle of decompensation before it happened and protect the patient and the staff.”
It’s an example of the effort de Nesnera and staff at NHH have made to address a problem that administrators, psychiatrists, and nursing staff on psychiatric inpatient units everywhere will recognize: the threat of violence and aggression on the part of patients that is directed at staff and associated with seclusion or restraint.
The initiative at NHH is comprehensive and involves administration, psychiatrists, nursing staff, law enforcement personnel, and community leaders. The effort also includes an ongoing research initiative designed to systematically gather data on aggression and violence, physical and verbal assaults and injuries, and variables associated with the occurrence of assaults.
In an interview with Psychiatric News, de Nesnera said the effort began in a formal way around 2008 and resulted from a “perfect storm” of factors also familiar to psychiatric administrators and staff: increasing demand and decreasing capacity for psychiatric care in the surrounding community, an influx of sicker, more complex patients frequently with substance use disorders in addition to mental illness, and forensic patients coming from secure psychiatric units in jails and prisons.
“Gradually we saw that we needed to address the issues associated with increasingly challenging patients with co-occurring disorders coming from a variety of settings,” he said. “We knew we needed to work comprehensively with staff and with community institutions and administrative entities before this challenge became a real crisis.”
The Substance Abuse and Mental Health Services Administration (SAMHSA) has issued a number of “issue briefs” and other resources on reducing and eliminating seclusion and restraint. SAMHSA notes that these measures can result in psychological harm, physical injuries, and death to patients and to staff. Rates of injury to staff in mental health settings that use seclusion or restraint have been found to be higher than rates of injuries sustained by workers in high-risk industries.
“In the early 2000s, there was a national effort to reduce seclusion and restraint,” said Diane Allen, M.N., R.N., assistant director of nursing for acute psychiatric services at NHH. She told Psychiatric News it was after a SAMHSA training session on the subject that staff at NHH decided to track and record the episodes that resulted in seclusion or restraint (and very often in injuries to patients and/or staff). “We decided we were going to elevate these events, make them visible for higher levels of review—for supportive reasons, but also so we could learn more about the root causes.”
Allen and de Nesnera initiated regular meetings involving administrative leaders, psychiatrists, and nursing staff to discuss incidents of verbal or physical violence. “We emphasized that these meetings would not be about criticism or second guessing what people did—otherwise, no one was ever going to come,” she said. “Rather, our approach was, ‘Tell us what happened.’ ”
Out of these discussions emerged certain patterns associated with violence: inadequate treatment of patients’ symptoms of paranoia or hallucinations, patient frustration with hospital rules, inconsistencies in protocols between different units, or the receipt of bad news.
In particular, Allen said, troubling news was a trigger. Patients would learn, for example, that they had lost their job, their wife had left them, or there was no one to take care of their dog
Interactions with civil courts were also liable to be a trigger. “We learned that the highest number of episodes requiring seclusion or restraint fell on Tuesday—which is the day our patients appear in court,” Allen said. “One of the features of court hearings is that a judge may tell patients that they will hear some resolution of their case by the end of the day. Often that doesn’t happen, and patients become extremely angry and agitated. So we talked to judges and educated them about giving patients realistic expectations about when they may or may not hear a resolution to their case.”
If “Staying Safe” was the on-the-ground strategy for reducing the threat of violence and injury to patients and hospital staff, there was a broader administrative strategy at NHH of reaching out to and working with institutions in the wider community to deal with systemic problems.
This included developing procedures for patients being “stepped down” from secure psychiatric units in jails or prisons (many of whom had been deemed not guilty of a crime by reason of insanity). Importantly, it also included working with hospital security police to create a “community policing” atmosphere on the unit, so that officers were regarded by patients as a familiar, benign presence—as opposed to a threatening and punitive one.
“Patients got to know the police officers in the friendly way that people in the community may get to know an officer who is regularly on the street,” de Nesnera said.
Additionally, de Nesnera and colleagues reached out to other state psychiatric hospital administrators in New England—including state hospitals in Maine and Vermont—to trade information and strategies for handling violent episodes. “We were able to share our experiences as to what it is like dealing with violent patients or with particular policies that were cumbersome,” de Nesnera said. “The ability to share our experiences and our expertise was really important and engendered a sense that we are all in this together.”
Tackling the problem of violence on inpatient psychiatric units requires hospital administrators to view the “big picture” while also being willing to work incrementally. You don’t have to reform the entire correctional system, de Nesnera suggested, but reaching out to educate one judge in the community—about mental illness, antisocial behavior, and hospital staff safety—can accomplish a lot.
“Administrators need to have a broad knowledge of the multiple systems working—sometimes together, sometimes not—on various aspects of mental health care for individuals,” he said. “But they should start with the ‘low hanging fruit’ to begin addressing systems issues that impede appropriate treatment of mentally ill patients. Once you do that, you can begin to work on the bigger problems.” ■