Violence and aggression in mental health‐care settings

Welcome to this special edition of International Journal of Mental Health Nursing, focussing on violence and aggression in mental health-care settings. While this is not a new agenda, to date, the journey travelled has been an interesting one, and the present agendas are quite different to those identified historically, albeit not in all aspects of care. For example, the use of the term ‘restrictive practices’ and the push for their minimization are relatively recent. As co-editors we first published our research in this area some 20 years ago when there was a distinct scarcity of research into coercive measures in mental health nursing practice (Muir-Cochrane 1995, 1996; Duxbury 1999, 2002). A lot has changed since then, and we offer some reflections to whet your appetite for this special issue. Aggression and violence are now a global concern in mental health settings. Early and timely recognition of the predictors of aggression and violence are recognized as crucial in facilitating the use of de-escalation strategies and avoidance of conflict situations (Jackson et al. 2014). Nevertheless, between 8% and 38% of health workers continue to suffer physical violence at some point in their careers (World Health Organization 2017), and we know that aggression and violence have a significant negative impact on the mental health and well-being of nurses, as well as their motivation to remain employed in nursing. As a response, health organizations in Australia have adopted a risk-based and zero tolerance approach to aggression and violence, which has effected how mental health nurses provide care. This approach continues to be used in Australia, although it is now considered dated and counterproductive in other countries. What we used to call ‘needs assessment’ in regard to planning care for consumers is now termed ‘risk assessment’. This change occurred as safety discourses in health care (patient safety, quality assurance, and quality improvement) emerged (Selmon et al. 2017). Originally, these discourses referred to the protection of the patient from hospital ‘harm’, such as medication errors or poor communication at handover. However, the risk discourse has evolved differently in spaces where mental health consumers/service users are cared for (emergency departments and psychiatric/mental health units). In regard to mental health consumers, risk has become situated with the consumer, the harms that he or she create, such as aggression and violence, suicide, or self-harm. Consumers with mental health issues have been restigmatized as spoiled identities and as threats to be forestalled for some time now (Goffman 2009). In the current Australian culture of mental health care, the way the consumer is seen to create the risk and risk assessment in a context of zero tolerance emphasizes the elimination and minimization of risk to protect all consumers and staff. Only recently have discussions about consumer safety occurred as a result of harms caused by the health-care system, including the extreme incidents of lack of care at Oakden in South Australia (Groves et al. 2017) and Winterbourne in the UK (Department of Health 2012). The agenda of minimizing restrictive interventions in UK settings gained significant momentum in 2011 following the Winterbourne Review. Subsequently a plethora of policy documents and guidelines have emerged in this area that endeavour to both raise awareness about and address the impact of such practices (Department of Health UK 2012, 2014, National Institute for Health & Care Excellence 2015). Historically referred to as ‘coercive measures’ (Kallert 2008), restrictive practices today are associated with the trauma of service users and staff, specific interventions, such as seclusion and restraint, and their negative impact on therapeutic relationships, organizations, and cultures. This is highlighted in this Editorial by the examination of service user perspectives about a number of associated matters and the condemnation of certain strategies as ‘evil’. It is argued that when de-escalation fails to manage consumer aggression and violence, restrictive interventions, such as physical restraint and seclusion, are used to maintain safety and to control consumers’ behaviour. These restrictive practices are recognized as detrimental to consumers and in direct opposition to practice using recovery-based and trauma-informed care approaches. For that reason, restraint-reduction practices in Australia have been supported for the past decade. In 2017, two key documents were published, aimed at establishing a best practice approach to support the goal of eliminating the use of restrictive practices by mental services. The documents are the ‘National Principles to Support the Goal of Eliminating Mechanical and Physical Restraint in Mental Health Services’ and the ‘National Principles for Communication about Restrictive Practices with Consumers and Carers’, launched alongside the establishment of the national restraint database, providing scorecards on all jurisdictions about their use of restrictive measures. Such initiatives and directives are not restricted to Australia and the UK, but originated in the USA (Huckshorn 2004), and are increasingly seen in Canada, Europe, and other countries, such as India. With all this in mind, this special collection of papers reflects contemporary national and international research focussing on safety, risk, aggression, and recovery-based consumer care. Papers discuss, inter alia, seclusion and analysis of prolonged duration of restrictive measures in forensic settings, evaluation of the Safewards model in seclusion reduction, and de-escalation strategies and restrictive practices. Additionally, a range of settings are examined, focussing on the experiences of staff in emergency departments and forensic and acute services, and the application of well-established, predictive tools to different areas. Philosophical debates about restraint as a necessary evil are particularly interesting, and the emergence and evaluation of specific minimization approaches, such as recovery rounds. Central to much of the debate and growing evidence in the papers in this edition are the experiences and accounts of service users and staff.

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