Background
Methods
The design of the study
The setting
Recruitment
Focus group questions and the data collection
Data analysis
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First, taped focus groups were transcribed [40] word for word by one author (TL) (4 focus groups) and a professional secretary (1 focus group). The text included altogether 134 pages (line spacing 1).
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Second, an overall picture was formed from the raw data by reading these transcriptions carefully; the aim was to become familiar with the original expressions that came out in the focus groups [42].
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Third, the transcribed text was read through again, keeping in mind the study questions under investigation and highlighting and making preliminary notes relating to the text at the same time. By doing this, ‘meaning units’ were formulated. A meaning unit can be words, phrases or paragraphs that include aspects related to each other [42].
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Fourth, meaning units related to the research questions were transferred to a separate MS Word document—and partly grouped during transfer. All highlighted meaning units were then condensed to codes [42]. Codes were considered to be more abstract and condensed labels for meaning units [42]. Each code can be reflective of several meaning units. In most cases the labels of codes came directly from the raw data [41].
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In the fifth phase of the analysis, all codes were then grouped into categories based on how different codes are related [41].
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Finally, sub-categories and categories were formed. Some of the sub-categories or main categories, or their definitions, started to emerge even when transcribing the focus group meetings. However, this final phase involved combining and organizing grouped codes into sub-categories and further, to categories [41].
Validity
Ethics, consent and permissions
Results
Description of the participants
Description of violent events on psychiatric wards
Signs of violence
They can be like blinking eyes more often or preening hair — (ID 5)
If one has to inform a patient about things that they will not like, it can be predicted that it might provoke violent behavior — (ID 1)
Targets of violence
— “I have had all kinds of, I mean threats that ‘I’m going to kill you’. That I will be killed, all my relatives, and even my cat.” — (ID 17)
Between the patients there is more verbal aggression, but there have also been some situations of struggle. (ID 7)
— an awful pounding was heard, we knew that soon there would be an alarm so we went there, and a patient was trying to break down the window with a chair— (ID 4)
Responsive action in violent events
There have been numerous times when I have seen a patient count how many [staff] were there and do nothing, until when there were less staff − which makes the situation ready. (ID 17)
We also offer a kind of opportunity where one goes to the seclusion room with open doors, to have a chance to be alone in peace. Some find being alone to be privilege, there is no one else provoking or whatever. One can go there on your own as well as freely leave. (ID 7)
— among the patients, there might have been some hero patient, who tries to protect the nurses from an aggressive rager, e.g. by scooping a nurse into safety in the nurses’ office. (ID 2)
Descriptions of ward climate during violent events
Overloaded with heavy workload
— long-lasting seclusion, which takes time and attention and energy from several nurses, and if there is less time for other patients, then you notice a kind of general anxiety which occurs — (ID 1)
Overloaded with emotions
— you are afraid, if someone sees your fear, the situation will be actually lost, you must just stay cool. (ID 8)— one cannot work if is afraid all the time. (ID 1)
Inducing cynicism
Somehow, one has learned to tolerate such heavy handling and one may easily start to respond in the same way. If someone is already using violence, the threshold for another to use it tends to become lower. Somebody’s life might derail because of a violent situation — (ID 2)
Suggestions of how violence prevention could be more effective
Category | Detailed suggestions | Example |
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In-service training | ||
To make treatment policies more coherent Should be more high-quality, concrete and offer new knowledge | Information: early warning signs, prediction of violence, new drugs and violence-related subcultures More in-service training for the all staff - especially de-escalation technique training |
To be able to practice together—the one who does and what, I suppose everyone knows broadly what to do, but what is their location at the situation, it demands some co-practice (ID 6)
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Competent interaction | ||
Staff-to-patient and staff-to-staff, e.g. between a nurse and a physician Interaction problems with a physician may endanger patient care: e.g. insufficient medication and lack of information provided to a patient | Courage to ask straight whether a patient has violence-related thoughts Consequences of violent behavior should be discussed clearly with the patient The importance of leadership and clear instructions clarification of nurses’ work in violent events A consensus among the staff how to deliver treatment Adequate, stable workforce: when staff knows each other well, interaction is easier |
It’s terribly hard for the patients, too — when there is no such line and they don’t have time to get used to anybody — it increases the risk that something might happen because such a stabile situation is aimed for in which everything is very consistent and everybody knows how to proceed, what they can and cannot do, it is always such a thing that holds the thing together (ID 17)
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Presence of nurses | ||
Patients being themselves, if ward climate tense and frustrated and can lead to violence | Familiar nurses provide safety for the patients Time to be present for the patients and a named nurse with primary responsibility to take charge if there are signs of violent behavior Only one of the nursing staff speaks to the patient in case of violent event |
That the more we can be there, so called present and displayed on the ward, so that way we can make the situations more calm (ID 17)
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Security improvement | ||
Lack of privacy and overcrowded wards Unsupervised places, e.g. smoking rooms, balconies Dysfunctional computers: if the files are unreachable, critical information may not be reported to next shift A patient or a visitor may smuggle drugs or bring weapons into wards | Reduction of beds, increase of single rooms for patients Avoidance of certain one-to-one situations, e.g. being twosome in kitchen with the patient Ensuring functioning electronic equipment for efficient reporting Compliance of security instructions: e.g. locked places should be locked When in doubt, permission to check patients’ bags even against patients’ will Drug detection dog on wards if needed Surveillance cameras and metal detectors on ward exits |
Neglecting such direct safety instructions, for example, locked places are left open, e.g. in the kitchen -knife drawers might be left unlocked, I think it is such a security deficit here, as well as dangerous chemicals, such detergents, might be unsupervised that one has a change to drink them for intoxication purposes (ID 3)
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