Managing Risks of Harm to Self and Others in Hospital

Aggression and Violence

Minimizing the risks and impact of violence is an increasing challenge for staff in acute inpatient wards [3]. Because of a trend to admit only the most acutely disturbed patients and for short periods, some wards are becoming ''anti-therapeutic'' environments where both staff and patients feel unsafe.

Limited staffing and poor building design can increase the risks to staff in inpatient units [42]. A volatile mix can develop in busy, noisy units with groups of young and unfamiliar patients confined by involuntary hospitali-zation and agitated by their psychotic experiences or mood disturbances.

Table 2.17 Response to aggression in an inpatient unit

• Distinguish between normal "adolescent" behaviour and symptoms of psychosis.

• Redirect energy through sport activities, walks with staff or other physical activity.

• Exert a high degree of self-control despite anxiety in the face of aggressive behaviour.

• Check what the patient wants: the issue might have arisen from difficulty with a simple request such as access to a phone.

• Avoid looking or becoming nervous: stay calm and self-confident.

• Recognize real threats and withdraw when appropriate: don't be a hero, and have the confidence to exit safely.

• Use a calm voice at low volume to convey simple messages.

• Adopt a non-threatening posture with some eye contact but avoid staring.

New arrivals can find their worst fears about hospital confirmed and become insecure and threatened. A vicious cycle develops as the therapeutic alliance breaks down, escalating confrontation and further increasing the risk of violence. Careful attention to staff morale, improving the quality of the inpatient milieu, and specific staff training in aggression management (especially preventive strategies) can help improve the situation.

Some aspects of dealing with aggressive patients were addressed above. Some additional techniques are outlined in Table 2.17.

Self-harm and Suicide

Assessment of the risks of self-harm and suicide were addressed in detail above. High risk of suicide is often a factor in deciding to admit a patient to hospital. Accurate risk assessment, close monitoring, removal of means of self-harm and optimal treatment (including psychological therapies as well as medication) are key steps in maintaining safety while on the ward. Formal classification of patients to different levels of nursing observation and severity will assist in this process.

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