Journal of Psychiatric and Mental Health Nursing, 2015, 22, 116–124
Substance use and violence among psychiatric inpatients D . S T E WA R T 1 1
& L. BOWERS2
Research Fellow, and Professor of Psychiatric Nursing, Institute of Psychiatry, Kings College London, London, UK
Keywords: aggression, alcohol,
containment, illicit drugs, inpatient, violence
Correspondence: D. Stewart Health Service and Population Research
Institute of Psychiatry
Kings College London PO Box 30 David Goldberg Centre
De Crespigny Park London SE5 8AF UK E-mail: [email protected]
Accepted for publication: 31 January 2014 doi: 10.1111/jpm.12144
Nursing staff on inpatient psychiatric wards often think that patient violence and aggression is caused by alcohol or illicit drug use. This study reports on how frequently patients use alcohol or drugs and whether this is linked to incidents of violence and aggression. There were relatively few incidents of substance use among the patients in the sample. There was no link between physical violence and substance use on wards, but there was an association with verbal aggression. More research is needed to examine how nurses intervene when a patient has used alcohol or drugs.
Abstract Nursing staff on psychiatric wards often attribute patient violence and aggression to substance use. This study examined incidents of alcohol and illicit drug use among acute psychiatric inpatients and associations between substance use and violence or other forms of aggression. A sample of 522 adult psychiatric inpatients was recruited from 84 acute psychiatric wards in England. Data were collected from nursing and medical records for the first 2 weeks of admission. Only a small proportion of the sample was reported to have used or been under the influence of alcohol (5%) or drugs (3%). There was no physical violence during a shift when a patient had used alcohol or drugs. Substance using patients were also no more likely than others to behave violently at any point during the study period. However, incidents of substance use were sometimes followed by verbal aggression. Beliefs that substance using patients are likely to be violent were not supported by this study, and could impact negatively on therapeutic relationships between nurses and this patient group. Future studies are needed to examine how staff intervene and interact with intoxicated patients.
Introduction Large numbers of psychiatric patients have a history of problems with alcohol or drug use, particularly in acute care settings (Carra & Johnson 2009). One UK study reported that 49% of patients with a diagnosis of psychotic illness screened positive for substance misuse or dependence (Phillips & Johnson 2003), while in the United States almost a third of adult hospital admissions with a primary psychiatric disorder have been estimated to have a comorbid substance use disorder (Blader 2011). 116
Substance use can have serious clinical consequences for psychiatric patients. It has been associated with more severe symptoms of schizophrenia (Bennett et al. 2009), excess mortality (von Hausswolff-Juhlin et al. 2009), elevated levels of suicidal ideation (Mordal et al. 2011), greater numbers of suicide attempts (Suokas et al. 2010), and increased risk of completed suicide (Haughton et al. 2005). There are physical health problems associated with the management of withdrawal symptoms that may require immediate medical attention (Raistrick 2000), and there is a risk of falls and injuries if patients © 2014 John Wiley & Sons Ltd
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are intoxicated (Hingson & Howland 1987). Potentially harmful interactions between alcohol, illegal substances, and antipsychotic medication require careful management. Rapid tranquillization in response to disturbed or aggressive behaviour should be accompanied by intensive monitoring by trained staff if a patient is suspected of recent substance use (National Institute for Clinical Excellence 2005). Patients with a dual diagnosis of psychosis and substance misuse have been found to have longer stays in hospital (Menezes et al. 1996, Wright et al. 2000) and to incur greater service use costs than those diagnosed with psychosis only (McCrone et al. 2000). Such patients present particular challenges for nursing staff because of the risk of continued use of substances during an admission. The traffic of people in and out of acute psychiatric wards and the rapid turnover of patients make it difficult to prevent alcohol and drugs getting onto wards (Quirk et al. 2006, Jones et al. 2010). An intoxicated patient can disturb others on the ward and there may be tension between patients with and without substance use problems (Quirk et al. 2004). Once a patient uses alcohol or drugs, there is a possibility that others will want to or be able to obtain these, and a ward can quickly gain a reputation for having a problem with substance use (Sandford 1995). Few studies have measured rates of substance use or intoxication while patients are in hospital, but in England about one incident of drug or alcohol use per week might be expected on an average 20 bed acute ward (Simpson et al. 2010), with one in 10 patients using alcohol or drugs during the first 2 weeks of admission (Bowers et al. 2005). The contribution of substance use to violent and aggressive behaviour appears to be of most concern to staff, patients, and visitors to wards (Sandford 1995; Royal College of Psychiatrists 2007). A national survey in England reported that 72% of nurses identified drugs use as a cause of disruption on wards, and 61% associated this with alcohol use (Chaplin et al. 2006). The same study found that both staff and patients mentioned substance use most frequently as a trigger for violence. There is a wellestablished link between substance use and violence among the severely mentally ill, although the direction of the relationship between these behaviours is complex. Substance use can increase the risk of violence, but this may be mediated by psychiatric symptoms and social factors (Swanson et al. 2006). A systematic review concluded that while schizophrenia and psychoses can be considered general risk factors for violence, substance abuse increases the risk regardless of whether or not this is accompanied by a comorbid diagnosis (Fazel et al. 2009). While in hospital, exacerbation of psychiatric symptoms among patients is often attributed by staff to patients’ drug use (McKeown & Leibling 1995, Sandford 1995, Ryrie & McGowan 1998, © 2014 John Wiley & Sons Ltd
Dolan & Kirwan 2001), and symptom severity is a distinguishing feature of patients diagnosed with psychosis and concurrent substance abuse compared to those with substance induced psychosis (Caton et al. 2005, Swanson et al. 2006). Few empirical studies have addressed links between substance use and violence on psychiatric wards. An analysis of a thousand violent incidents concluded that substance use was a contributing factor in only 1% of cases (Powell et al. 1994). Further UK studies have identified substance use as a precursor to violence in 2% (Shepherd & Lavender 1999) and 1% (Duxbury 2002) of cases. Similarly, a study of aggression in four Australian psychiatric inpatient units showed that only 3% were the consequence of alcohol and drug use (Barlow et al. 2000). Guidelines for the National Health Service suggest the following potential interventions for managing an incident of substance use or intoxication: increased observation and security, locking ward doors, restriction of visitors, and post-incident review (Department of Health 2006). Unfortunately, very little empirical information is available about how the behaviour of intoxicated or substance using patients is actually managed on wards. There is evidence that intoxicated patients may be placed in a seclusion room (Bowers et al. 2010), if the ward has this facility, and that hospitals sometimes use special observation to manage drug or alcohol withdrawal (Bowers et al. 2000). Patients can subjected to breath tests (alcohol), urine tests (drugs), or blood tests (both alcohol and drugs), but this is more common upon reasonable suspicion of use rather than on admission, return from leave, or on a random basis (Simpson et al. 2010). Positive drug tests may in fact have a minimal influence on the management of patients, although referral to specialist services, changes to leave entitlement, increased observation, medication changes, and discharge can follow (Ghali 2009). The present study measured incidents of substance use and violence from nursing and medical notes. The aims were to examine: the frequency of alcohol and drug use in the sample; whether substance use preceded or followed incidents of violence or other forms of aggression; other patient behaviours and staff interventions associated with substance use; patient characteristics associated with substance use.
Method Design This was a cross-sectional, retrospective case note study conducted in 2009–2010. For each selected patient, data were collected on all incidents of conflict (e.g. self-harm, 117
D. Stewart & L. Bowers
absconding, violence, medication refusal, substance use) and containment (e.g. intermittent special observation, constant special observation, manual restraint etc.) during the first 2 weeks of the current admission. The study was approved by Kings College Research Ethics Committee (17/04/2009; 09/H0808/13). The researcher approached selected patients and provided them with information about the study in order to participate. Those patients who agreed to discuss the study were given an information sheet and had the opportunity to raise any concerns with the researcher before being asked to consent.
Sample A sample of 522 patients was recruited from 84 acute psychiatric wards in 31 hospital locations in London and surrounding areas. The sample was stratified by hospital and ward, excluding patients admitted for less than 2 weeks. Patients were eligible to participate if they were inpatients of the selected acute wards, 18–65 years old, had stayed in hospital for 2 weeks or more, and were present on the ward when the survey was conducted. Patients were also required, in the opinion of staff, to have sufficient capacity to give informed consent to participate at the time of the researcher’s visit. When visiting a ward, the researchers liaised with nursing staff to identify eligible patients, of whom six were randomly selected to participate (judged to be the maximum that could be recruited per researcher day). In total, 1902 eligible patients were selected to participate. Of these, 973 (51%) were deemed by staff to be too ill to approach or were off the ward at the time of the researcher’s visit (e.g. on leave). A further 407 (21%) refused to participate.
Data collection Data on involvement in incidents of conflict and containment were collected using the Patient-staff Conflict Checklist (PCC) case notes version. The PCC is accompanied by strict definitions for each conflict and containment event. A previous study of medical and case note entries demonstrated an inter-rater reliability score of 0.69 for this instrument (Bowers et al. 2005). For this study, the PCC was expanded and a computerized version created, so that the order of events within shifts and days could be collected, as well as counts of events. Shifts with no conflict or containment were also recorded (null events). A range of demographic and background data were collected including: age, gender, ethnicity, diagnosis, living group, previous admissions, history of substance use, history of aggression towards self or others, and whether admitted involuntarily under the Mental Health Act. After informed consent was 118
obtained, the researcher accessed the patient’s medical and nursing records for approximately 60 min to complete the PCC. Data were entered directly on to a laptop computer. In addition to two university-based researchers, 18 Mental Health Research Network (MHRN) Clinical Studies Officers were also trained to collect data from the participating wards.
Data analysis The study examined the sequence of events preceding and after an incident of substance use or intoxication. The data were organized so that each row represented the sequence of events within one patient shift, providing a total of 21 924 patient-shifts for the whole 2-week period. Each row detailed the order and nature of conflict and containment events. A total of 9691 conflict and containment events were recorded. If more than one incident of drug or alcohol use was recorded for a patient, the sequence of events for each was analysed separately (i.e. the number of sequences equals the number of substance use events). Comparisons of the prevalence of particular conflict and containment events in the alcohol and drug sequences were assessed by chi-square tests. Patients who used alcohol and drugs during the first 2 weeks of admission were compared to the remainder of the sample. Variables included were: age, gender, ethnicity, marital status, history of alcohol misuse, history of drug use, any significant physical health problems, previous selfharm, previous violence, psychiatric inpatient history, and whether an admission was voluntary. Logistic regression analyses were first performed to identify individual variables associated with alcohol and drug use (P < 0.1). These variables were then entered into a multivariate logistic regression model with backward elimination of nonsignificant (P < 0.05) covariates and controlling for clustering by hospital. Statistical analyses were conducted using Stata 11.0 (StataCorp 2009).
Results The majority of the sample (54%) were male, white (68%), had at least one previous inpatient episode (85%), and were voluntary (60%) admissions. The mean age was 41.1 years (SD = 13.04). Primary diagnoses included: schizophrenia or schizoaffective disorders (44%), affective disorders (38%), and personality disorders (11%). Sixty-three per cent had a history of self-harm, 57% had a history of harming others, 37% had used illicit drugs, and 40% had a history of excessive alcohol use. There were 38 incidents of alcohol use and 28 incidents of drug use during the 2-week period. Alcohol use was © 2014 John Wiley & Sons Ltd
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and aggression at any time during the 2-week period. Patients who used alcohol were significantly more likely than other patients to be verbally aggressive during their admission (81% vs. 50%; χ2 = 10.10, P = 0.001), but there were no significant effects for physical violence or aggression towards objects. Similarly, patients who used drugs during their stay were more likely to be verbally aggressive only (88% vs. 51%; χ2 = 9.38, P = 0.002). Prior to alcohol use, 73% of conflict and containment events involved absconding (either leaving or returning to the ward). This compares with 26% of drug-related incidents preceded by absconding behaviours, of which 11% were attempted absconds. Successfully absconding from the ward was significantly more likely to precede alcohol than drugs (24% vs. 4%; χ2 = 5.07, P = 0.024), but the difference for returning from absconding did not reach statistical significance (21% vs. 7%, χ2 = 2.43, P = 0.119). One incident involved a patient absconding and returning to the ward under the influence of both alcohol and drugs, and two of the three drug sequences involving a return from absconding also included use of alcohol. The methods which staff used to manage use of alcohol and drugs differed slightly, with incidents involving alcohol more frequently managed by de-escalation and drugrelated incidents more frequently followed by pro-re-nata medication. In general, however, most incidents of drugs (79%) or alcohol (71%) were followed by no containment at all. Manual restraint, seclusion, and referral to psychiatric intensive care were used after incidents of drug use but
recorded for 27 patients (5.2% of the sample) and drug use for 17 patients (3.2% of the sample). Five patients had used both alcohol and drugs.
Alcohol and drug sequences Events before and after alcohol and drug use during a shift were examined. Typically, incidents of alcohol and drug use did not involve other forms of conflict or use of containment during a shift. Sixty-one per cent of alcohol use incidents were not preceded by a conflict or containment event, and in 53% none were reported afterwards. This includes seven alcohol use incidents which involved the simultaneous occurrence of other events: three were returning from absconding, two were attempted suicide, and two involved a change of legal status. For drug use, the respective proportions were 67% and 70%. Where conflict and containment was reported, the frequency of these events is shown in Table 1. There were no recorded incidents of physical violence to persons during any of the sequences. Other forms of aggression (verbal or to objects) were more common after than before incidents of drug and alcohol use, lending some support to the belief that patients who use drugs or alcohol can become aggressive. In total, 24% of events after alcohol use and 26% of events after drug use involved verbal aggression or aggression to objects. Analyses were conducted to assess relationships between patients who had used alcohol or drug use on the wards Table 1 Conflict and containment before and after incidents of substance use Alcohol
Pre n Conflict Verbal aggression Aggression to objects Alcohol Illicit drugs Smoking Attempted abscond Abscond Return from abscond Demanding pro-re-nata medication Sexual Refusing to see workers Refusing to eat Refusing to go to bed Refusing pro-re-nata medication Self-harm Containment De-escalation Pro-re-nata medication Other containment
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2 2 2
10.5 10.5 10.5
5 2 2
18.5 7.4 7.4
3 4 6
11.1 14.8 22.2
1 2 4 3
2.6 5.3 10.5 7.9
8 2 3
21.1 5.3 7.9
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Table 2 Factors associated with alcohol and drug use Alcohol
Age History of excessive alcohol use
0.004 0.05) variables. The final models are shown in Table 2. Younger patients and those with a history of excessive alcohol use were significantly more likely to have used both alcohol and drugs during their admission. Because all the patients who used drugs were single and had a history of drug use these variables could not be entered into the drug use regression analyses. Since previous alcohol and drug use were correlated with substance use on the wards, we constructed statistical models for these variables. We also wanted to assess whether patients with a history of substance use were more likely to engage in violent and aggressive behaviour in hospital. The logistic regression analyses followed the same procedure as before, but with incidents of physical violence, verbal aggression and aggression to objects included as additional independent variables. Having a history of drinking problems was not associated with any form of aggression on the ward (Table 3). Rather, these patients were more likely to be male, to have used illicit drugs, to have self-harmed in the past, and to be a formal admission to the hospital. They were also less 120
Table 3 Factors associated with a history of alcohol problems
Female Previous drugs Previous self-harm Formal admission Diagnosis Schizophrenia Affective disorder Personality disorder
0.45 4.71 2.43 1.65
0.3 3.04 1.41 1.09
0.69 7.31 4.17 2.48
0.000 0.000 0.001 0.017
0.34 0.48 0.81
0.17 0.24 0.34
0.68 0.96 1.9
0.003 0.039 0.623
Table 4 Factors associated with a history of drug use
Age Female Previous alcohol Previous violence Verbal aggression (on ward)
0.93 0.59 4.64 1.71 1.79
0.91 0.42 2.8 1.12 1.15
P 0.95 0.84 7.72 2.62 2.78
0.000 0.003 0.000 0.014 0.009
likely to be diagnosed with schizophrenia or affective disorders. However, there was a relationship between previous drug use and verbal aggression during the admission (Table 4). In addition to the link with alcohol problems, previous drug use was more likely for males, younger patients, and those who had been involved in violence before.
Discussion Among this sample of acute inpatients, no incidents of physical violence against another person were found during a shift when a patient had used alcohol or drugs. Nor were patients who had used alcohol or drugs more likely than others to behave violently during the study period. Our results would appear to counter the previously reported expectations of nurses that substance use among inpatients is a cause of violent behaviour (Sandford 1995, Chaplin et al. 2006). Either there was no direct link between substance use and violence on the wards or nursing staff were adept at preventing substance use escalating to disruptive and violent behaviour. Since the vast majority of incidents of alcohol or drug use did not result in any further conflict or containment the former explanation is the more prob© 2014 John Wiley & Sons Ltd
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able. The findings are only partially consistent with a previous study of acute wards in England which reported no association between drug use and violence but did find a relationship for alcohol use (Bowers et al. 2009). However, that study counted the overall frequency of events on wards, whereas the present analysis is based upon data for individual patients. The discrepancy in findings may mean that patients under the influence of alcohol can have a disturbing influence on others in the ward but are not necessarily at greater risk of behaving violently themselves. The results should not, therefore, encourage complacency about the need to develop strategies to control alcohol consumption among this population. There was a clear and consistent relationship between substance use and verbal aggression. Verbal aggression is much more common on psychiatric wards than violence to others or to objects (Foster et al. 2007). While nurses can to some extent become accustomed to this (Adams & Whittington 1995), verbal aggression can have serious consequences including staff burnout (Bowers et al. 2009), post-traumatic stress (Adams & Whittington 1995), and feelings of anger, anxiety, fear, or guilt (Needham et al. 2005). Levels of verbal aggression increased after incidents of alcohol and drug use, but this did not appear sufficient for nursing staff to intervene and de-escalate the situation or to use alternative means of containment during the shift, perhaps because staff are more used to this form of aggression (Whittington 2002). However, there was a significant association between substance use and verbal aggression during the full 2-week study period (rather than confined to the shift). Since staff tended not to directly intervene when substance use was suspected, this verbal aggression may have been triggered when the incident (and any potential sanctions) was discussed at a later stage, when the patient was no longer intoxicated. If so, there are two risk periods for aggression: when the patient is actually under the influence of alcohol or drugs and when staff initiate a discussion with the patient about their behaviour. The precise nature of such interactions between staff and patients was not measured by this study, but the few studies which have done so indicated that nurses employ a nonconfrontational approach, involving cautioning, counselling or closely observing the patient (Ryrie & McGowan 1998). Distraction techniques, non-verbal communication, providing explanations, and building rapport are skills which can reduce aggression (Spokes et al. 2002). There may be some reluctance among nurses to enforce substance use screening procedures because of its potentially punitive consequences and the risk of damaging therapeutic relationships with patients (Loubser et al. 2009). The most notable conflict event to precede substance use was absconding or attempting to abscond from the ward, © 2014 John Wiley & Sons Ltd
especially before incidents of alcohol use. Previous studies have noted consumption of alcohol and drugs by patients who have left the ward without permission (Bowers et al. 1999, Dickens & Campbell 2001). Three incidents of alcohol use were recorded as occurring simultaneously with a patient returning to the ward after absconding. These patients had evidently consumed alcohol while off the ward and returned in an intoxicated state. However, it was more common for alcohol use to be recorded as occurring after the patient had returned, possibly because the patient had secreted alcohol to be consumed on the ward or their intoxication was not apparent at the time they re-entered the ward. Alternatively, the absconding event itself may have prompted nurses to suspect or test the patient for substance use. Biological monitoring of substance use is frequently used either upon reasonable suspicion, randomly or when patients return from leave but together with locking ward doors, these measures have not shown significant statistical relationships to levels of use on wards (Simpson et al. 2010). Suspicion of substance use among patients returning to the ward (from absconding or leave) is likely to have been greater for those known to have problems with alcohol or drugs. All those who had used drugs during the 2-week study period had a history of drug use recorded in their nursing notes, and previous problems with drinking was a predictor of both alcohol and drug use on the ward. That substance use on wards was more likely for patients with existing problems with drugs or alcohol is consistent with previous research which found over 80% of patients identified as alcohol or drug misusers to have used substances during their admission (Phillips & Johnson 2003). The results emphasize the importance of identifying substance use problems during admission assessments, which have been poorly detected in the past (Barnaby et al. 2003). There were contrasting findings for the relationship between previous substance use and aggression during an admission, with a significant effect for use of drugs but not for alcohol. Together with a link to previous harm to others, this provides some justification for the anxiety among staff that drug using patients are a potential source of difficulty on the ward, although again these findings pertain to verbal aggression and not violence or aggression to objects. For patients with a history of excessive alcohol use, the greater concern is their previous harm to themselves. Not every patient who used alcohol during their admission was recorded as having a drinking problem, suggesting that it is the circumstances of incidents which trigger verbal aggression, or the nature of alcohol intoxication, rather than the characteristics of problematic drinkers who are admitted to the ward. 121
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There are some limitations to this study. The precise circumstances of each incident were not recorded, so we do not know what or where patients had been drinking or the types of drugs which patients had consumed, although the drug most commonly used by inpatients is cannabis (Phillips & Johnson 2003, Isaac et al. 2005). Patients’ substance use history was identified from the admission summaries available in the case notes, rather than from administration of a standardized tool. We also relied upon the accuracy of the nursing notes for identification of incidents of substance use or intoxication on the wards. Such incidents tended not to be accompanied with biological measures to confirm substance use, and it is possible that there were some under-reporting. Previous inpatient studies have identified deficiencies in the detection and recording of drug and alcohol problems (Ley et al. 2002, Barnaby et al. 2003) as well as variations between wards in the methods and frequency of substance use monitoring (Simpson et al. 2010). The absence of containment measures after incidents of substance use does not necessarily mean that no action was taken. It is possible that patients who were found to have consumed alcohol or drugs were sanctioned, for example by not being granted leave from the ward or being subjected to searches. Such events did not fall within our definition of containment and were not recorded by the study. Similarly, patients may have accessed alcohol or drugs while on leave from the ward (as with patients who had left without permission). Significant leave tends to come later in an admission, when a patient has stabilized, so the 2-week study period could have limited the opportunities for substance use among the sample. Although patients on the wards were randomly sampled, a large proportion of those selected refused or were unable to participate at the time of the researchers’ visits to the wards. Many of the refusals were because of patients’ concerns about allowing access to case notes, but the exclusion of these patients may have biased the sample in some way. We did not have access to admission or other data to determine how many of the non-participants had substance use problems or the nature of any other potential sources of bias. Finally, our sampling strategy excluded patients admitted for less than 2 weeks, and such patients may have differed significantly, for example using more drugs or
alcohol and with a greater association between use and aggression.
Conclusions The perception among nurses that alcohol and drug use contributes to inpatient violence was not substantiated by the findings of this study. In our sample, substance use was not accompanied by any physical assaults. There was a link with verbal aggression, but most incidents of substance use were isolated and not associated with any other conflict or containment events. Patients with comorbid substance use problems have complex health and social needs, and nurses may have legitimate concerns about managing these and the risks associated with them. Nurses have been found to be significantly less likely than other health professionals to feel adequately trained in managing the medical consequences of drug or alcohol misuse (O’Gara et al. 2005). Previous research indicates that dual diagnosis training can improve the confidence of nurses (Cameron et al. 2010; Munro et al. 2007), but the impact may be limited and insufficient on its own to adequately address the overall attitudes of staff and the needs of patients (Hughes et al. 2008). More information is required about the effect of such training on nurses’ relationships with patients as well as incidents of conflict behaviours. There is a clear and pressing need to provide evidence-based guidance to staff as to how intoxicated or substance using patients should best be supported once admitted to hospital. This will require further studies to examine in much more detail how nurses intervene when a patient is suspected of substance use and how this differs to the management of other challenging patient behaviours.
Acknowledgment This paper presents independent research commissioned by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (RPPG-0707–10081) and supported by the NIHR Mental Health Research Network. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, or the Department of Health.
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