Journal of Psychosocial Nursing and Mental Health Services

CNE Article 

Violence Factors and Debriefing in Psychiatric Inpatient Care: A Review

Jaana Asikainen, MSc; Katri Vehviläinen-Julkunen, PhD, RN, RM, FEANS; Eila Repo-Tiihonen, PhD, MD; Olavi Louheranta, PhD, ThM

Abstract

The aim of the current review was to identify, analyze, and synthesize the available research on violence factors in psychiatric care and the potential of debriefing to reduce the incidence of violence necessitating coercive measures. A two-part electronic search was conducted using multiple databases. Part 1 focused on reviews and meta-analyses relating to violence factors published between 2007 and 2017. Part 2 focused on articles on debriefing published after 2000.

Two hundred ninety-five articles on violence factors and debriefing were identified, from which 39 publications were selected for detailed analysis. Results indicate that patient characteristics, management, staff approaches, and the ward environment are influencers that may trigger violent incidents. Several violence factors in psychiatric care have been identified. Nursing communication, leadership, and debriefing are among the most effective ways of reducing violence in psychiatric care. [Journal of Psychosocial Nursing and Mental Health Services, 58(5), 39–49.]

Abstract

The aim of the current review was to identify, analyze, and synthesize the available research on violence factors in psychiatric care and the potential of debriefing to reduce the incidence of violence necessitating coercive measures. A two-part electronic search was conducted using multiple databases. Part 1 focused on reviews and meta-analyses relating to violence factors published between 2007 and 2017. Part 2 focused on articles on debriefing published after 2000.

Two hundred ninety-five articles on violence factors and debriefing were identified, from which 39 publications were selected for detailed analysis. Results indicate that patient characteristics, management, staff approaches, and the ward environment are influencers that may trigger violent incidents. Several violence factors in psychiatric care have been identified. Nursing communication, leadership, and debriefing are among the most effective ways of reducing violence in psychiatric care. [Journal of Psychosocial Nursing and Mental Health Services, 58(5), 39–49.]

Aggressive incidents and violence occur frequently in psychiatric health care facilities and hospitals and cause serious problems in mental health care units (Cutcliffe & Riahi, 2013a,b). Consequently, many studies have examined the prevalence (Cornaggia et al., 2011) and nature (Hahn et al., 2010) of patient-to-professional violence. Previous studies have focused on nurses' and patients' perceptions of the causes of patient violence (Iozzino et al., 2015). There are considerable differences in reported rates of violence in psychiatric care, as well as its definition, measurement, and cultural variation (Iozzino et al., 2015). Violence affects patients and staff, producing emotional effects, such as anger, shock, fear, depression, and anxiety (Cornaggia et al., 2011), as well as economic effects. Thus, there is a need to inform health care professionals about alternative actions against violence, such as debriefing (Huckshorn, 2008).

A perceived risk of violence usually increases the likelihood that staff will adopt coercive measures such as seclusion (e.g., locking a patient in a room), restraint (e.g., tethering a patient to a bed), or medication administration to control violence (Bowers et al., 2011; Cornaggia et al., 2011). Patients often regard and describe coercive measures as traumatic. Consequently, the use of such measures can retraumatize patients instead of promoting engagement and cooperation with treatment (Kontio et al., 2012).

Seclusion is one of the strongest measures available to psychiatric nursing staff (Slemon et al., 2017) and the most common method used to control threat of violence and violent behavior among patients (Bowers et al., 2011; Kontio et al., 2012). To avoid conflict between constitutional rights and the need to control violent behavior in patients with psychosis, it is desirable to reduce the incidence of violence and the development of situations in which staff may feel a need to use coercion and seclusion and restraint (Duxbury et al., 2011; Rakhmatullina et al., 2013).

Several strategies exist for reducing the use of seclusion and restraint. These strategies are frequently implemented collectively within a broad-based program aiming to reduce seclusion and restraint (Ash et al., 2014; Blair & Moulton-Adelman, 2015; Putkonen et al., 2013; Wieman et al., 2014). Debriefing is one of the Six Core Strategies for Reducing Seclusion and Restraint Use (Huckshorn, 2004) and has been identified as a key element of successful seclusion and restraint reduction programs (Sutton et al., 2014). Various tools exist to improve communication and assess the risk of violence (Cutcliffe & Riahi, 2013a,b; Tolisano et al., 2017). Some of these tools can be implemented during debriefing, such as asking patients what they might find helpful, respecting patients' choices, and giving them enough time to respond (Goetz & Taylor-Trujillo, 2012; Huckshorn, 2008; National Institute for Health and Care Excellency [NICE], 2014).

Studies on debriefing (Bak et al., 2014; Godfrey et al., 2014; Goulet et al., 2017; Jonikas et al., 2004) suggest patients be included in the development of their treatment and crisis plans. Debriefing helps avoid misunderstandings and violence. Staff should treat patients with respect and discuss their treatment in a suitably respectful manner. Psychiatric nurses and other mental health professionals should, therefore, receive training in effective communication (Bowers et al., 2011). In addition to good communication and patient care, it is essential to have a safe and comfortable environment that can make treatment actions meaningful (Huckshorn, 2008; LeBel et al., 2014; Maguire et al., 2012).

The current review is important for mental health care because violence is common in psychiatric hospitals and imposes significant costs on communities. Violence also has significant adverse physical and psychological effects on patients and staff. Therefore, effective means, such as debriefing, are needed to prevent violence.

Aim

The aim of the current review is to summarize and synthesize the research literature on debriefing and factors (e.g., environmental, individual) that affect violent behavior among inpatients. There is a need to identify triggers that may increase the likelihood of violent behavior among inpatients to reduce its occurrence. Three research questions were posed: (1) Which factors influence inpatient violence in psychiatric wards?; (2) What do debriefings in psychiatric inpatient care cover?; and (3) Which violence factors can be affected by debriefing?

Method

Ethical approval was granted by the Northern Savonia hospital district Ethics Committee. Preliminary searches showed that qualitative and quantitative methods have been used in previous studies on violence and debriefing in psychiatric care; therefore, it was necessary to adopt a strategy that enabled the synthesis of original studies using widely differing methods (Joanna Briggs Institute [JBI], 2014; Whittemore & Knafl, 2005).

The objective of the review was to explore factors that influence the incidence of violence and the way these factors are affected by debriefing. Therefore, the review was divided into two parts. Part 1 focuses on the perpetrators of violence and factors associated with violence, whereas Part 2 focuses on the impact of debriefing. Only reviews, meta-analyses, and publications describing violence models were considered for inclusion in Part 1. Part 2 used a scoping review methodology to study the impact of debriefing on inpatient violence (Arksey & O'Malley, 2005; Peters et al., 2015). This approach is particularly useful when seeking to comprehensively and systematically map the literature on complex topics to identify key concepts, theories, recommendations, and research gaps (JBI, 2015).

The parameters of scoping reviews do not typically require rigorous evaluation of the methodological quality of the reviewed studies or documents (Peterson et al., 2017); the emphasis is on comprehensive coverage rather than achieving a particular standard of evidence. Therefore, the quality of individual studies was not assessed in Part 2 of the review (Arksey & O'Malley, 2005).

In both parts, the review process involved the following five stages: (a) identifying the problem, (b) conducting the literature search, (c) evaluating the data, (d) performing the analysis, and (e) presenting the results (Whittemore & Knafl, 2005).

Data Collection and Evaluation

Part 1: Violence Factors. Electronic databases Scopus and PubMed were searched for reviews and meta-analyses published between January 2007 and December 2017. Search terms and phrases were formulated based on preliminary searches after consultation with an information specialist at the University of Eastern Finland. The following keywords were used: (“inpati*” OR “mental health*” OR “psychiatry”) AND (“violen*” OR “aggress*”) AND/OR (“seclusion” or “restraint”) AND/OR (“model,” “review,” or “meta-analyses”). Articles were included if they examined adult inpatients or mental health violence factors and discussed the prevalence of violence. In the current study, violence is defined as any behavior or action (physical or verbal) that may cause harm, hurt, or injury to another person. Previous studies generally used similar definitions. Only articles written in English and published in peer-reviewed journals were eligible for inclusion. Exclusion criteria were a focus on outpatients or non-psychiatric settings, suicide, medication studies, non-academic studies, and being written in a language other than English.

The searches yielded 189 articles that were read by two researchers (J.A., O.L.) to identify factors reported to increase or reduce violent or aggressive behavior in forensic or inpatient units (Figure 1). The NICE (2014) “safe staffing” guidelines were used to facilitate this process. The articles were also evaluated against the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA; 2015) checklist. Studies with multiple deficiencies according to this checklist were excluded, as well as five duplicate records, leaving 13 articles (seven reviews, two meta-analyses, and four models) for inclusion in the review.

Flow diagram of the search and selection processes.

Figure 1.

Flow diagram of the search and selection processes.

Quality assessment of the identified articles was also performed using the System for the United Management, Assessment and Review of Information (SUMARI), which is a tool for conducting systematic literature reviews developed by the JBI. Articles reporting qualitative and quantitative research were chosen for inclusion. The quality of the qualitative articles was assessed using the Qualitative Assessment and Review Instrument (QARI). This instrument evaluates studies with respect to 10 criteria, including philosophical starting points, methodology, and ethical principles (JBI, 2014). The quality of the quantitative papers was assessed using the Meta-Analysis of Statistic Assessment and Review Instrument (MAStARI; JBI, 2014). This instrument evaluates articles with respect to nine criteria, including the use of randomized and blinded groups (JBI, 2014).

The 13 articles selected for inclusion were found to be of reasonable quality, receiving scores of 6 to 7 of 9 (MAStARI) and 6 to 8 of 10 (QARI). The most common quality deficiency among the qualitative studies was failure to identify the researchers' cultural or theoretical approaches, which determine the congruity between a study's philosophical perspective and its methodology. The most common quality issue with the quantitative studies was a reliance on non-randomized samples.

Part 2: Debriefing. To broaden the search results, no limits on the type or level of debriefing or the debriefing guidelines were applied during the search. The search was conducted using the following databases: MEDLINE/PubMed, CINAHL/EBSCO, EMBASE, Scopus, PsycINFO, and the Cochrane Database of Systematic Reviews. Combinations and synonyms of the following terms were used: (“inpati*” OR “mental health*” OR “psychiatry”) AND (“debrief*” or “post-seclusion” or “post-restraint “or “post-incident”). Although the focus of the review was on debriefing following coercive actions, debriefings following chemical or physical restraint events were also included. All research studies and academic publications were eligible for inclusion in the scoping review. The initial search yielded 106 articles that were subjected to a screening process to assess their relevance to the review (Figure 1). As a result, 70 articles were excluded because they did not satisfy the eligibility criteria (i.e., did not discuss debriefing), were duplicates (n = 10), or could not be retrieved (n = 4). After full-text reviews of the remaining publications, 26 articles were found to satisfy the eligibility criteria. There was some overlap between the sets of articles identified during the two parts of the review. Thus, 189 articles were considered in Part 1 and 106 in Part 2, with a total of 295 articles considered in the entire review process (Figure 1).

Study Characteristics

Of the 13 primary violence articles selected for analysis, four were systematic reviews (Cornaggia et al., 2011; Gudde et al., 2015; Health Quality Ontario, 2017; Witt et al., 2013) and one was based on an integrative synthesis (Foronda et al., 2016). In addition, there were articles discussing violence models (Cutcliffe & Riahi, 2013a,b; Goetz & Taylor-Trujillo, 2012; Tolisano et al., 2017) and meta-analyses (Dack et al., 2013; Iozzino et al., 2015; Papadopoulos et al., 2012; Zhou et al., 2016). Most studies originated from the United States (n = 4) or United Kingdom (n = 3). Participants were patients, nurses, and other mental health experts.

The debriefing articles (n = 26) were published between 2003 and 2017. Six articles were literature reviews (Gaskin et al., 2007; Goulet & Larue, 2016; Goulet et al., 2017; Jacobowitz, 2013; Scanlan, 2010; Van Der Merwe et al., 2013), one was a retrospective association study (Bak et al., 2014), six were qualitative studies (Bonner & Wellman, 2010; Lanthén et al., 2015; Larue et al., 2013; Lee et al., 2003; Ling et al., 2015; Ryan & Happell, 2009), one described a randomized controlled trial (Putkonen et al., 2013), three were case studies (Goulet et al., 2018; Larue et al., 2013; Whitecross et al., 2013), and two were retrospective reviews of records (Needham & Sands, 2010; Riahi et al., 2016). Of the 26 articles, most came from the United States (n = 7), Canada (n = 6), the United Kingdom (n = 3), and Australia (n = 5).

Data Analysis

The selected articles were analyzed to gather data on the studies and their findings. Narrative synthesis was conducted by grouping the data, and similar groups were combined to identify relationships between studies. Results were then extracted for analysis, compared, grouped based on content similarity, and coded into subcategories. The content was then classified at higher levels of abstraction by grouping the subcategories into main categories, which were named inductively based on their content. For example, two factors identified in the original data for the violence review were “a non-overcrowded setting” and “a good ward climate” (Cornaggia et al., 2011). These were assigned to the “environmental factors” subcategory, which belongs to the main category “violence factors.” This approach revealed key factors associated with violence and debriefing, including factors relating to inpatients, the environment, management, and the actions of health professionals.

Results

Factors Influencing Inpatient Violence in Psychiatric Wards

Violence can be attributed to distal and proximal factors. Distal factors are events from a patient's past, such as a history of childhood abuse or drug use, whereas proximal factors are events or phenomena that coincide with the violent event, such as being angry, having communication difficulties, or experiencing severe hallucinations (Cornaggia et al., 2011; Dack et al., 2013; Witt et al., 2013). In addition, violence factors can be classified as physical (e.g., patient restraint, prolonged hospitalization), cultural, or environmental (e.g., overcrowding). Factors can also relate to patients' personal characteristics, such as diagnosis of psychotic and/or personality disorder (e.g., schizophrenia); history of violence, self-destructive behavior, or substance use; patient age (30 to 40); gender (male); and history of impulsiveness (Allen et al., 2018; Cornaggia et al., 2011; Dack et al., 2013; Iozzino et al., 2015; Renwick et al., 2016; Witt et al. 2013; Zhou et al., 2016).

Environmental factors, management practices, and the actions of staff as well as staffing levels in a ward all affect the occurrence of violence in psychiatric units (Figure 2). Violence models and several reviews (Cutcliffe & Riahi, 2013a,b; Goetz &Taylor-Trujillo, 2012) indicate that patients can become frustrated and more prone to violence in response to many environmental factors relating to the ward atmosphere, including hurriedness or restlessness, lack of privacy, poorly designed architecture, staff shortages, poor daily programs, lack of activities, discomfort, and the culture within the treatment setting (Cornaggia et al., 2011; Ling et al., 2015; Ramsden, 2019). These factors suggest that violence may be prevented by designing physical structures that offer comfort and grant patients privacy and freedom of movement. In addition, patients need daily programs and meaningful activities to avoid frustration (Cutcliffe & Riahi, 2013a,b; Goetz &Taylor-Trujillo, 2012; Ramsden, 2019).

Violence factors and debriefing in psychiatric care.

Figure 2.

Violence factors and debriefing in psychiatric care.

A ward's comfort and functionality affect the likelihood of violent incidents and can be increased (or decreased) by leadership actions. Managers should therefore consider functionality, ward rules, and the environment as interactive aspects of patient care (Goetz &Taylor-Trujillo, 2012; Health Quality Ontario, 2017; Scanlan, 2010). Leadership strongly affects the working climate and the way staff treat patients in health care units and has direct and indirect effects on the incidence of patient violence (Foronda et al., 2016; Goetz &Taylor-Trujillo, 2012; Scanlan, 2010).

Good management and nurses' interactions and communication with patients, their families, and other carers are central to good health care (Gudde et al., 2015; Health Quality Ontario, 2017). Unfortunately, communication and patient-handling skills of nurses are often incomplete. Certain personality traits or behaviors of nurses may increase the likelihood of violence, such as not communicating with patients, inadvertently provoking them with poorly chosen words, or not showing empathy (NICE, 2014). The most effective way of de-escalating an aggressive patient appears to be for staff to try to understand the patient's problem, encourage reasoning, and ensure that their non-verbal communication is non-threatening and non-provocative (Cutcliffe & Riahi, 2013b; Foronda et al., 2016; Gudde et al., 2015). Debriefing is one way to understand patient's actions.

Debriefing in Psychiatric Care

The purpose of debriefing after a violent incident that necessitates the use of seclusion or restraint is to investigate the incident and develop strategies to avoid its reoccurrence (Gaskin et al., 2007; Putkonen et al., 2013; Wieman et al., 2014). Huckshorn (2004) suggests that the purpose of debriefing is to also ensure the safety of patients, nurses, and the wider organization. It is important for debriefing to be conducted as soon as possible after a critical event. The debriefing process involves supportive conversations between staff and patients who were involved in the event (Lewis et al., 2009). The benefit of this process is that it supports learning at staff, management, and organizational levels while information about the incident is fresh, increasing the likelihood that meaningful plan revisions will follow (Azeem et al., 2011; Fisher, 2003; Lewis et al., 2009).

Several studies (Bonner & Wellman, 2010; Jacobowitz, 2013) have discussed the importance of debriefing as a way of acknowledging and managing the potential distress and trauma caused by the use of seclusion and restraint. Debriefing gives opportunities for staff and patients to reflect on their behaviors after a seclusion or restraint event so as to prevent the reoccurrence of coercive practices. Two studies (Goulet et al., 2018; Ryan & Happell, 2009) highlighted the importance of debriefing for rebuilding trust and therapeutic relationships between staff and the patient after the critical event.

Sutton et al. (2014) found that debriefings are typically conducted at three main levels, all of which are important for preventing violence. The first is the ward level, at which management and staff discuss the seclusion event and openly express their thoughts, emotions, or opinions about it in a supportive and blame-free environment. The second level is patient debriefing, which can be used as a tool to prevent the recurrence of seclusion or restraint (McCue et al., 2004). This discussion can relieve distress and help the patient and staff recognize the behaviors that led up to the use of seclusion or restraint, possibly leading to a revision of the patient's care plan. This level involves patient behavioral analysis, education, problem-solving, and planning (Sutton et al., 2014). Before conducting such debriefing, the patient's recovery and their physical and emotional status should be assessed. Debriefing should never be forced, and patients should have a range of realistic options in terms of who facilitates the debriefing and when it occurs to help restore a sense of control over their care. Allowing patients to be supported by a representative can strengthen their voice when addressing clinical or organizational issues (Huckshorn, 2018; Sutton et al., 2014). The final level of debriefing is the organizational level. Debriefing at this level enables in-depth analysis of seclusion and restraint events, with a focus on finding alternative ways to (a) prevent the use of seclusion and restraint and (b) provide further support to staff or patients who have experienced or witnessed violence (Sutton et al., 2014).

Descriptive studies (Needham & Sands, 2010; Ryan & Happell, 2009) describe patient debriefing as an element of a broader seclusion or restraint prevention strategy. Similarly, several quantitative studies (Azeem et al., 2011; Fisher, 2005; Putkonen et al., 2013; Sclafini et al., 2008) examined patient debriefing as one component of a successful seclusion and restraint reduction program. However, only two articles (Needham & Sands, 2010; Van Der Merwe et al., 2013) highlighted the importance of tracking the frequency of debriefing and the need to evaluate the content of debriefing and follow up on the matters discussed. Needham and Sands (2010) also emphasized the need for documentation of debriefings. The debriefing guidelines proposed by Sutton et al. (2014) state that the purpose of executive-level review (debriefing) is to evaluate the critical event and facilitate quality improvement throughout the organization.

Debriefing and Violence Factors

Interest in reducing physical harm often leads to a neglect of emotional and psychological harm (Bowers et al., 2011). Consequently, little attention has been paid to emotional or psychological harms that may be associated with mental illness, psychiatric treatment, and the associated restrictions on patient freedom and autonomy. Aggressive behavior on an inpatient's part affects his/her emotional state, mood, and experience of pain. Studies have shown that mental states such as fear and paranoia can significantly increase the risk of aggressive and violent behavior (Dack et al., 2013). Management, patient care, and communication between staff and patients have significant impacts on violent behavior (Dack et al., 2013; Gudde et al., 2015; Witt et al., 2013). Debriefing creates opportunities to improve the environment and communication and prevent the reoccurrence of violent events that lead to the use of coercive practices (Gaskin et al., 2007). Five articles explored immediate debriefings with patients following seclusion and restraint events (Bonner & Wellman, 2010; Goulet & Larue, 2016; Goulet et al., 2018; Ling et al., 2015; Ryan & Happell, 2009). Other studies (Bell & Gallacher, 2016; Goulet et al., 2018; Larue et al., 2013; Lee et al., 2003) emphasized the importance of communication and emotion management in violent situations. None of the studies showed the importance of debriefing concerning environmental changes in inpatient wards. This sub-area needs more research. However, learning and understanding from environments and situations that led to violence was highlighted as an important aspect of preventing violence from reoccurring.

Several studies (Needham & Sands, 2010; Ryan & Happell, 2009; Whitecross et al., 2013) identified debriefing as a means of mitigating distress following seclusion and restraint. However, these studies provide little guidance on the content or process of psychologically focused debriefings. Overall, the reviewed articles highlight the need to better understand the needs of patients and staff, enable expression of emotion during debriefing, and develop frameworks for post-incident support.

Patients reportedly value having someone who will listen to and understand their experiences of seclusion and restraint (Lanthén et al., 2015). It seems that debriefing helps patients understand their own pathology of violence (Lee et al., 2003) and to influence and participate in their own treatment (Ling et al., 2015). Debriefing can thus reduce patient frustration and violence, as well as strengthen the confidential relationship between staff and patients and can help staff anticipate potentially violent situations in the future (Bonner & Wellman, 2010; Jacobowitz, 2013; Riahi et al., 2016; Ryan & Happell, 2009).

Discussion

The purpose of the current review was to identify, analyze, and synthesize the available research on inpatient violence factors and the effects of debriefing following violent incidents to facilitate the development of effective strategies for improving safety in psychiatric units. Because these issues are poorly understood, there is a need to integrate the results of previous studies to more accurately assess the effectiveness of different interventions and to make recommendations that can help health professionals and organizations make decisions about specific interventions or care issues.

This review, which is based on 39 scholarly articles, identifies factors that affect violence and the impact of debriefing and ways of improving the latter so as to reduce the incidence of the former. Factors found to affect violence were related to the patient, environment, management, and communication. Debriefing can be influenced by management, environment, and communication factors, for instance by encouraging staff and managers of psychiatric wards to change their approaches to communication and improve conditions in psychiatric care units. This review also shows that violence is hard to prepare for and anticipate; therefore, tools and effective targeted interventions are needed to reduce its occurrence.

The security culture in psychiatric facilities is defined by relationships, leadership, staff, patients, and the environment, together with values, beliefs, and guiding principles (Allen et al., 2018; Cutcliffe & Riahi, 2013a,b). Management style at the organizational level is particularly important because it sets the ethical values and goals that provide the basis for preventing patient violence. In addition, management practices strongly influence the atmosphere of a ward. Good managerial practices promote open discussion and positive feedback, as well as the importance of staff in addressing security concerns, for example by distributing information on violence-reducing tools. A culture of dialogue can improve security. To establish such a culture, there must be interactions between management, staff, and patients. The review also indicated that staff training can reduce violence (Goetz &Taylor-Trujillo, 2012; Health Quality Ontario, 2017).

Nurses may use different forms of coercion, such as seclusion, restraint, and medication, to exert control and prevent patients from acting violently because they are unaware of other ways of controlling patient violence (Bowers et al., 2011; Huckshorn, 2008). These methods can be effective in the short term. However, in the long term, it is important to implement interventions to change unfavorable behavioral patterns and improve communication (Bowers et al., 2011; Goetz &Taylor-Trujillo, 2012; Tolisano et al., 2017). The concept of recovery-focused care relies on debriefing and a positive patient–nurse alliance in which nurses teach patients alternatives to aggressive behavior (Goetz & Taylor-Trujillo, 2012). Cornaggia et al. (2011) concluded that the most effective strategy for preventing violence is to create a good caring and working climate with harmony among staff. Debriefing studies support this position (McCue et al., 2004; Riahi et al., 2016; Ryan & Happell, 2009). Such a climate can be created by adopting good communication techniques, ensuring staff are available to patients, and providing patient education. Studies have shown that continuous training in preventing violence and the use of tools and strategies can reduce violence and coercive actions (Huckshorn, 2008; McCue et al., 2004; Whitecross et al., 2013). Staff actions can also affect the effectiveness of treatment, incidence of violence, and patient safety. Many seclusion events result from misunderstandings or lack of communication and differences in perception (Goulet & Larue, 2016). Nurses may mistakenly attribute a patient's actions to his/her psychiatric disorder rather than factors that could be changed by the nurses themselves or the ward manager (Mistry et al., 2015). Patients' desires and input should be given greater weight during their treatment (Maguire et al., 2012).

A safe physical and psychological environment has been identified as a critical factor in patient and staff well-being. The physical atmosphere affects patients' mood and comfort; accordingly, the literature indicates that ward designs with suitable physical spaces, furnishings, and lighting can increase patients' sense of security (Cornaggia et al., 2011; Cutcliffe & Riahi, 2013a,b; Foronda et al., 2016). Threats and unrest among violent patients can be reduced by ensuring that wards have a clear orientation with a well-defined daily program and instructions. The literature indicates that patients should be given meaningful work and a sense of ownership over the ward (e.g., being invited to help plan its decoration) (Papadopoulos et al., 2012; Tolisano et al., 2017). In addition, patients should be involved in designing ward activities and rules. Reducing patient violence (Cornaggia et al., 2011; Goulet & Larue, 2016; Lambrinos & Holubowich, 2017) requires active efforts to modify the organization's patient safety culture. Better plans are also needed for further treatment to avoid violent situations and improve patient–staff relationships. A common vision for resolving issues with patients must be developed.

Debriefing plays an important role in providing feedback for individual patients and staff, as well as entire organizations. The literature indicates that debriefing must be integrated into the seclusion and restraint process rather than a stand-alone intervention (Goulet et al., 2018; LeBel et al., 2014). Effective debriefing requires strong leadership as well as staff commitment and adequate training (Allen et al., 2009; Goulet & Larue, 2016; Goulet et al., 2017; Scanlan, 2010). The current review identified several common points relating to debriefings that could be used to reduce the incidence of violence.

The first of these common points is that there is clear evidence that debriefing can reduce the incidence of violence when used as part of a violence-reduction strategy (Azeem et al., 2011; Fisher, 2003; Jonikas et al., 2004; Putkonen et al., 2013; Riahi et al., 2016). The second is that several studies (Bonner & Wellman, 2010; Jacobowitz, 2013) have demonstrated the importance of immediate nurse and patient debriefing to accurately gauge the distress and trauma due to violent incidents and the use of seclusion and restraint. Debriefing provides an opportunity to discuss difficult situations and emotions and to rebuild trust with the patient in the care relationship. However, Whitecross et al. (2013) concluded that patients and staff need multiple debriefing sessions because a single debriefing would not be enough to prevent or reduce symptoms of post-traumatic stress disorder in patients or staff.

Debriefing also has some problems, and more studies (particularly quantitative studies involving randomized controlled trials or comparison group studies) are needed to increase understanding of its effects. Multiple studies have shown that debriefing is not consistently conducted after incidents of patient violence, seclusion, or restraint (Larue et al., 2013; Ryan & Happell, 2009).

A need also exists for further studies on the debriefing process. Although several investigations (Goulet et al., 2018; Ling et al., 2015; Needham & Sands, 2010) and guidelines (Sutton et al., 2014) have emphasized the significance of monitoring the content of immediate patient and staff debriefing, there is a clear need for more research on the individual, clinical, organizational, and administrative challenges that nurses experience after a seclusion or restraint event, which may prevent nurses from conducting immediate patient and staff debriefing (Bonner et al., 2002; Lanthén et al., 2015; Larue et al., 2013). In addition, Sutton et al. (2014) have argued that debriefing should be conducted at organization, ward, and individual levels. Taken as a whole, the evidence base on debriefing is insufficient to robustly define its purpose or to draft reliable guidelines for its implementation because the literature is dominated by descriptive publications that focus on the experiences of staff and patients. There are no descriptions or trials of culturally specific interventions, and experimental studies that could reveal correlations or causality are absent.

One thing that the debriefing literature clearly shows is that debriefing is not routinely conducted after violent incidents, and that approaches to this intervention are inconsistent. Nevertheless, there is compelling evidence that debriefing is valuable, in accordance with its status as a core strategy for reducing seclusion and restraint (Huckshorn, 2004). Patients have expressed a desire for debriefing (Bonner et al., 2002; Faschingbauer et al., 2013) and agree that it is useful (Bonner & Wellman, 2010) in the aftermath of seclusion or restraint. Debriefing gives patients an opportunity to understand and change their behavioral responses to distress, anger, or frustration. The current review also indicates that a more open atmosphere is key to developing a sense of community in psychiatric wards and weakening cultures of compulsion and violence and that discussion plays an important role in establishing connections among patients, staff, and the wider organization. Finally, the results presented show that psychiatric communities should consider their practices holistically because it is relatively straightforward for staff and managers to modify the ward environment and their approach to communication, both of which can significantly affect the incidence of violence and the use of seclusion and restraint.

Limitations and Strengths

This review has several weaknesses as well as strengths. The limitations of this review relate to the subject of the study, search strategy, and heterogeneity of the selected studies (Whittemore & Knafl, 2005). An important strength is that only peer-reviewed articles describing systematic violence models and reviews were included in the analysis. The expertise of a university information specialist was drawn on to ensure comprehensive literature coverage, and unpublished studies and abstracts from conference proceedings were excluded to avoid basing conclusions on low-quality sources. The violence studies were evaluated according to the criteria of the JBI and the PRISMA checklist by two reviewers. Studies were only eligible for inclusion in the review if they satisfied at least 70% of the PRISMA criteria. Conversely, all articles on debriefing identified in the search were included in the review.

Another notable limitation of this study arises from the shortcomings of the databases that were searched (i.e., publications not included in the databases could not be included in the review) and the exclusion of publications in languages other than English. In addition, many of the qualitative studies included in the review did not clearly state the researchers' cultural or theoretical approaches, which determine the congruity between the philosophical perspective of the research and its methodology. This ambiguity limits the validity of conclusions drawn by aggregating the results of such studies. Thus, all situational, contextual, historical, interpersonal, and cultural phenomena that affect patient violence and the impact of debriefing were unable to be considered.

Nursing Implications

Management, nurses' actions, and ward environment play an essential role in preventing patient violence. Better communication with patients can help them express themselves without violence. Debriefing is one way of addressing patients' feelings, thoughts, and wishes for their own care and addressing difficult situations of violence. Debriefing can also increase patient well-being and promotion of care.

Conclusion

The information on patient debriefing and risk factors for violence among psychiatric inpatients presented in the current review can be used to inform the design of improved strategies for health care management and the training of health care professionals, helping further the development of resources and practices in mental health care.

Rates of violence in acute psychiatric wards in Western countries appear to be high and highly variable between wards and settings. In general, patients who have many risk factors for violence appear to experience higher levels of violence. Although some of these risk factors cannot be changed because they relate to the patient's life history and symptoms, others relate to factors that can be influenced by the actions of nursing staff and managers. It is important to understand the factors associated with individual violent episodes and to use interventions, such as debriefing, to protect patients and staff from violent acts.

The results presented can help promote collaborative care in psychiatric wards and reduce the incidence of violent events and coercive actions. The extent to which inpatient characteristics contribute to violent behavior can be compared to other risk factors and service-related failings, all of which require further exploration. In addition, more information is needed about de-escalation methods for preventing violence. It would be valuable to study patients' perspectives on the use of such tools and methods, possibly by debriefing after incidences of seclusion or restraint.

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Authors

Ms. Asikainen is PhD Student, Dr. Vehviläinen-Julkunen is Professor and Chair, Department of Nursing Science, Dr. Repo-Tiihonen is Assistant Professor in Forensic Psychiatry, and Dr. Louheranta is Supervisor, Department of Forensic Psychiatry, University of Eastern Finland; Ms. Asikainen is also Head Nurse, Dr. Repo-Tiihonen is also Medical Director, and Dr. Louheranta is also Supervisor, Niuvanniemi Hospital, Kuopia, Finland. Dr. Vehviläinen-Julkunen is also Professor, Kuopio University Hospital, Kuopio, and Dr. Repo-Tiihonen is also Assistant Professor in Psychiatry, University of Helsinki, Helsinki, Finland.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This project received financial support from Niuvanniemi Hospital.

Address correspondence to Jaana Asikainen, MSc, Head Nurse, Niuvanniemi Hospital, Niuvankuja 65, FI-70240 Kuopio, Finland; e-mail: jaana.asikainen@niuva.fi.

Received: November 14, 2019
Accepted: January 07, 2020
Posted Online: March 11, 2020

10.3928/02793695-20200306-01

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