When the ward is the patient: Using the PRISM protocol to understand and reduce violence in an inpatient intellectual disability setting

Background

Violence in inpatient settings is recognised as a worldwide issue, with inpatient intellectual disability services having higher rates than other mental health settings. Violence results in injury and illness, lack of confidence in the organisation and staff burnout. These combined effects have a negative impact on the ability of services to provide therapeutic environments. Attempts to manage violence tend to focus on the individual. This is only one part of the solution. Situational risk factors for violence within secure settings can be identified and modified to reduce violence rates. The role of situational risk factors in rates of institutional violence requires consideration in addition to individual patient risk assessment and management.

Aims

To discuss an illustrative case study of a ward experiencing high levels of violence, resulting in staff burnout and low morale. To describe how assessing and addressing the relevant situational risk factors led to demonstrable reductions in violence and improvements in the service provided.

Methods

This case study demonstrates the practical application of assessing and managing situational risk factors for violence in a locked intellectual disability ward in order to effectively reduce levels of violent incidents. A description of the violence and critical issues faced by the ward is provided, noting key elements of the timeline of events and the application of the Promoting Risk Intervention by Situational Management (PRISM) process to address these.

Results

The PRISM protocol enabled a comprehensive assessment and understanding of situational factors relevant to the violence rates in the ward. The recommendations following the analysis enabled the management team to identify areas for immediate and long-term action. Practical steps to address issues such as improving soundproofing were implemented quickly whilst other issues required changes over the longer term. Significantly, reduced levels of violence were observed within a 2-month period of immediate steps being taken, with further gains achieved over the longer term.

Conclusion

This paper provides the only example of the use of the PRISM protocol in an intellectual disability inpatient setting. The reduction in violence seen in this unit provides ‘real world’ evidence that addressing situational factors for institutional violence can be effective in intellectual disability inpatient settings, with beneficial outcomes for patients and staff. Whilst individual patient risk assessment and risk management are key components of forensic mental health care, situational risk factors for violence are highly relevant to rates of violence within secure care settings. Structured assessment of situational risk factors should be considered when inpatient settings experience persistent high levels of violence. Further research on the impact of assessing situational risk factors in forensic mental health settings (including intellectual disability services) would help to develop the existing evidence base.