Enhancing Safety and Well-Being: Interventions for Reducing Self-Harm and Violence in High-Risk Adult Facilities.

Prisons and psychiatric environments are the places where the risk for self-harm and violence is very high. As it is a frequent phenomenon, it is an urgent matter that can affect the security and life quality of the community members greatly, who are vulnerable to such problems. Consequences include a range of injuries from minor to life-threatening, disability, loss of life, and moodicity disorder (Fernando et al., 2022). The people who engage in self-harm or extremely violent acts normally have an unacknowledged mental illness or substance abuse history, or their history has been so devastated that a high potential for complex interventions to suit their specific needs is present (Brown et al., 2023). One of the consequences of self-harm, suicidal behaviors, and a high risk of violence in these working conditions include not only those directly involved but also the community members as well as the support staff who bear increased risks of psychical and emotional strain which last longer due to the stressful nature of the work environment (McIvor et al., 2023). It is no secret that cases of severe distress and harm can disrupt the therapeutic atmosphere, which is counterproductive to other residents’ or patients’ progression (McIvor et al., 2023). Hence, in such institutions, non-aggressive and the recovery of those involved in it can be allowed. Using programs and reform-oriented processes can help individuals abolish negative behaviors and establish a therapeutic setting where healing and restoration can be done. The main aim of this paper is to select the current literature on the topic of the policies and interventions that feature adult facilities with the risk of violence and self-harm). Based on the literature, evidence-based recommendations will be formulated.

Significance of the Practice Problem

Disproportionately high rates of harm, such as self-injury and violence, constitute a major public health risk to those in detention in environments of elevated danger, like prisons and psychiatric hospitals, thus endangering the safety of most susceptible adults. These dangerous behaviors can also be seriously hazardous, leading to serious injuries, trauma, or even death. This is not only a great personal burden for the affected person, but it can also lead to increased costs for the healthcare system (Fernando et al., 2022; McIvor, 2023). Persons who are cut off and present threatening acts usually suffer from a range of mental health problems, including addiction disorders and post-traumatic stress, and the quality and depth of their treatment are vital (Brown et al., 2023). The consequences of self-destruction and violence in such type of prisons are not limited to the prisoners themselves but also spread into the general population and the staff on support, where increased rates of injuries, emotional distress, and burnout experienced due to the extremely adverse environment are observed (McIvor et al., 2023). Besides, these behavior disturbances result in an impairment of the therapeutic atmosphere, which leads to the creation of obstacles in the path of other patients who want to recover their health (McIvor et al., 2023). In high-risk sites, self-harm and violence are hot items that should be mitigated for safety and mass recovery rather than for any other reason. Strong interventions could display a powerful and cathartic effect on the vicious circle pre, create a risk-free environment, and offer rehabilitation and healing opportunities.

PICO-Format Clinical Question

The clinical question in this paper is framed using the PICO format: For individuals who live in facilities for people experiencing homelessness (P), is the implementation of specific safety measures and patient-centered activities (I) compared to routine care (C) an underlying factor in reducing incidents of unhealthy behavior such as the self-harm and violence and eventually bettering of the health status (O)?

Population

High-risk facilities, such as prisons, forensic psychiatric institutions, and psychiatric hospitals, wherein estimation of the target population shows the involvement of adult inmates. This type of person might be prone to self-harm in addition to abuse and other turbulent emotions such as substance addiction, mental health issues, or sudden trauma. Besides, it would be worth mentioning that both the elderly who are forced there vary in age, and there may be differences in motives even though they have similar needs. For example, inmates in correctional centers who are subject to confinement and long periods of isolation and lack proper psychiatric services report suffering from increased consequences such as the stress of the confinement, more social isolation, and stressful interactions with prison officials. However, mental health patients in psychiatric medical facilities can be battered by two distinct mental health scenarios (McIvor et al., 2023): acute or chronic mental illnesses may be seen but require regular specialized medical interventions and an environment that is welcoming to clinical services. Also, the interventions that have been planned to help deal with the particular challenges of these individuals may be efficiently customized according to the different sub-groups that fall under this class, with more focus on specific measures. These situations may include different levels of complexity, such as household violence, sex violence, mental disorders, and drug or alcohol abuse, necessitating special intervention and systems (Westers & Plener, 2020).

Intervention

The interventions under investigation are the implementation of certain safety protocols and individualized patient safety interventions for groups prone to self-harm and violence, in particular in high-risk residential adult facilities. These interventions can be broadly categorized into three main domains: policy development, environmental modifications, treatments, and flagging through SOPs. The change in environmental factors is the modification of a facility for the sake of avoiding suicidal or violent behavior; they include the elimination of ligature opportunities, better vision, providing viewing corners, and the creation of certain safety equipment (Griffiths et al., 2022).

The line of treatment includes several approaches based on the research and other psychological methods such as cognitive-behavioral therapy (CBT), dialectical behavior therapy (DBT), and treatments for trauma and substance abuse (Brown et al. (2023), Shobhana & Raviraj (2022)). Staff competency and emergency protocols embrace delivering staff with specialized training dealing with the risk factors, de-escalation techniques, and evidence-based protocols for self-harm or violence management (Zarska et al., 2023). Risk assessment tools are rendered appropriately to limit the transmission of the virus (Beghi et al.,2021; Westers & Plener,2020). These initiatives almost always form a complex system as research has shown that an approach targeting different components – the environment, staff training, and the therapeutic dimension – usually is believed to be the most effective measure to reduce incidents with acts of self-harm and violence (van de Ruit & Bosk, 2021).

Comparison

The control group in the context of this research is a standard care service plan, usually a standard in high-risk institutions that implement procedures and protocols to prevent self-harm and violence. In the standard paradigm of practice, these monitoring, observation, and response ran,ge from th,e least to the most. The effectiveness of the specific safety protocols and intervention programs will be compared to standard care that currently exists in order the collect evidence on whether these measures will result in a reduction of harmful acts or promote long-term mental health wellness.

Search Strategy and Results

To address the PICO question, a comprehensive literature search was conducted using the following databases: PubMed, CINAHL, PsycINFO, and the Cochrane Library. The search was limited to studies published in English within the last five years (2018-2023). The following MeSH terms and keywords were used in various combinations across these databases: “Self-Injurious Behavior,” “Violence,” “Risk Reduction Behavior,” “Psychiatric Department, Hospital,” “Prisons,” “Adult,” “self-harm,” “aggression,” “high-risk facilities,” “safety protocols,” “interventions.”

The initial search yielded a total of 478 results. After screening titles and abstracts for relevance and applying inclusion criteria (randomized controlled trials, cohort studies, systematic reviews, and meta-analyses focusing on interventions for self-harm and violence in high-risk adult facilities), 35 studies were selected for full-text review. Following the full-text review, ten studies were included in the final synthesis. Only articles were withdrawn that did not focus on interventions related to self-harm or violence, as well as adult facilities with a high risk of these issues. Studies in non-adult populations or those that did not have relevant outcomes were excluded. Of the ten included studies, 3 were randomized controlled trials, 2 were cohort studies, 3 were systematic reviews, and 2 were meta-analyses. These studies recommended a variety of methods (e.g., environmental modifications, treatment approaches like CBT and DBT, staff training, and safety protocols) as being effective in reducing the likelihood of individuals with mental illness engaging in conflicts.

Synthesis of the Literature

The literature review identified the main issues and patterns implemented in interventions for addressing self-harm and violence in adult high-risk programs. The evidence strongly supports environmental modifications as an effective approach to preventing self-harm. Griffiths et al. (2022) used a time series design. They found that interventions enhancing sightlines, removing suicide points, and providing safe areas led to a significant decline in self-harm incidents among patients in adolescent inpatient psychiatric wards. Additionally, a systematic review by van de Ruit and Bosk (2021) identified upgrading the environment as an essential factor that improved visibility and restricted patient access, which can be interpreted as an effective way to prevent self-harm in inpatient settings.

Some evidence suggests that CBT and DBT, which are based on psychological and behavioral treatments, can help reduce self-abusive behaviors and improve overall wellness (Brown et al., 2023; Shobhana & Raviraj, 2022). Furthermore, Brown et al. (2023) highlighted the significance of early identification and intervention for individuals at risk of developing symptoms indicating trauma history, depression, and early signs of borderline personality disorder. They emphasized the importance of evaluating and utilizing evidence-based treatments like DBT.

Several research works highlighted the significance of extensive employee training and implementing an integrated approach to reduce the occurrence of self-harm and assault in acute care wards. In the framework of systemic review by Zarska et al. (2023), the working group proved that nursing specialist training and adherence to safety protocols reduce rates of patient self-harm more effectively than in cases when training and safety protocols are not followed. Zarksha and friends (2023) mentioned that along with providing regular training to frontline healthcare workers on safety principles and suicide prevention, it becomes a pivotal point that needs to be seriously paid attention to in the self-harm reduction process. Researchers confirm that the most effective way to avert violence and self-harm in high-risk populations is not through one guiding model but a blend of guided approaches from various streams, including environment, psychotherapy, and staff training (van de Ruit & Bosk, 2021). It is, though, that ecological variables are of great importance, and van de Ruit and Bosk (2021) argue that therapeutic interventions and multidisciplinary teams have more definitive roles they ought to succeed in addressing; consider the mental issues of self-harm as a case study.

These studies underscored the significance of the presurgical evaluation as well as the maintenance of care after that as the crucial elements of postoperative care. Wester and Plener (2020) tend to evaluate the suitability of the tools produced by different studies to assess the risk. However, irrespective of the accuracy level they recommend those with the structured approach to be the best than the unstructured clinical estimations. According to Beghi et al. (2021), procedures and strategies concentrating on risk groups particularly come in handy for people at risk of suicide, being referred for screening and follow-up, people experiencing social withdrawal, and others who are unclear of the risk burnout involved. Among those studies underlined the demand for diversified interventions being targeted to the separate subunits within the at-risk adult group. To give a clear example, Brown et al. (2023) emphasized the treatment program and services that started in the early stages of the disorder, such as the forms of diagnostics methods, drugs used, and the interventions for the younger generation struggling with depression, trauma, and borderline personality disorder. It has also been found by Wand et al. (2022) that social isolation is one of the factors that need to be given priority in the intervention modalities developed to avert self-harm by the geriatric population at risk.

Hence, the literature recommends the implementation of a complex set of interventions, comprising environment modifications, various types of therapies, and comprehensive safety procedures, that have more chances to succeed than traditional care in preventing violent and aggressive behavior among high-risk inmates (van de Ruit & Bosk, 2021). Nevertheless, such studies emphasize the importance of continued research along with adjustments to account for the specific needs of different stages and environments.

Practice Recommendations

Based on the evidence from the literature synthesis, the following practice recommendations can be made to reduce self-harm and violence in high-risk adult facilities: Emotions are most dangerous when they take us to the edge, so let us focus our efforts on the following environmental changes: reduction of ligature risks, improving visibility, and creation of special safety outfits (Griffiths et al., 2022). Develop and improve CBT and DBT, which are core components of the treatment process, while using specific tools that are based on each individual’s need (Brown et al., 2023; Shobhana & Raviraj, 2022). Organize training programs for the staff on how to spot risk signs, de-escalating methods, and evidence-based protocols ( Zarska et al., 2023). Adopt holistic risk appraisal techniques and security systems such as (Bogi & Ömer Aydin, 2021 and Wehmer & Karin Plener, 2020). Apply a multidiscipline approach, including cooperation between different experts for considered care (van der Ruit & Bosk, 2021). Provide mitigation measures targeting specific subgroups, with trauma survivors and those with substance use disorders being a primary focus (Brown et al., 2023). Establish procedures for self-harm condition screenings, referrals, and follow-through (Beghi et al., 2021). Work with partnership services in order to provide smooth patient discharges and tackle problems such as loneliness (Meyerhardt et al., 2022). Conduct an effectivity audit of the intervention via incident reports, feedback from staff, and patient outcomes while using emerging evidence in accordance to modify or further develop protocols. Support is needed for worker safety by spending resources for providing comprehensive interventions in the field of risk mitigation to reduce costs in the long run (van de Ruit, B. & Bosk, D. 2021). The recommendations should be structured for each given condition applicable to the institution, and they should be upgraded and critiqued to improve interventions for arising needs and to keep pace with time.

Conclusion

The main conclusion is that the new offering ought to be the actions-based programs as an effectual measure for the violence and self-harm in the adult facilities populations. Not one intervention is the solution; however, a multi-factorial approach that includes environmental changes, human intervention techniques, staff training, and comprehensive safety measures has been more effective in preventing self-harm and violent behavior compared with usual nursing practice. Following this path, thus, the impressive life quality for those who are struggling with mental disorders is the outcome. The community practice propositions illustrated in this article have all the needed components. They can play a role in the feeling of safety in the target environment and reaching the assumed goal of improving the well-being of adults in these places. In the event of fulfilling these suggestions, no one will have the right to put at risk the well-being of other residents, and, on the contrary, the mentioned policy will give them a chance to help vulnerable individuals progress in rehabilitation and recovery.

It must be, however, noted that these measures are constantly evolving processes, which need to be steadily assessed as well as adjusted to reflect new findings and novelties. Also, we should have all the right people and equipment in order to run the program smoothly and effectively. Further researches need to be done to fill in the gaps no longer serviced by ongoing projects to include program results, varied staff training approaches, and strategies for specific categories of people. Appropriately designed studies, which evaluate strategies’ impacts on different situations and research, are needed in order to enhance effective policies. Ideally, the objective here is to provide an ambiance that is free of violence and conducive to a better passage to recovery for the individuals living under the watch of these institutions. Not only by applying the evidence-based practices that deal with self-injury and violence to support disadvantaged adults, staff members in these organizations also aid in creating a healthcare system where compassion is an essential quality.

References

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Fernando, S.M., Ranzani, O.T. & Herridge, M.S. Mental health morbidity, self-harm, and suicide in ICU survivors and caregivers. Intensive Care Med 48, 1084–1087 (2022). https://doi.org/10.1007/s00134-022-06743-9 

Griffiths, R., Dawber, A., McDougall, T., Midgley, S., & Baker, J. (2022). Non‐restrictive interventions to reduce self‐harm amongst children in mental health inpatient settings: Systematic review and narrative synthesis. International Journal of Mental Health Nursing, 31(1), 35–50. https://doi.org/10.1111/inm.12940 

McIvor, L., Payne‐Gill, J., & Beck, A. (2023). Associations between violence, self‐harm, and acute psychiatric service use: Implications for inpatient care. Journal of Psychiatric and Mental Health Nursing, 30(3), 451–460. https://doi.org/10.1111/jpm.12872 

Shobhana, S. S., & Raviraj, K. G. (2022). Global trends of suicidal thought, suicidal ideation, and self-harm during COVID-19 pandemic: a systematic review. Egyptian Journal of Forensic Sciences, 12(1), 28. https://doi.org/10.1186/s41935-022-00286-2 

van de Ruit, C., & Bosk, C. L. (2021). Surgical patient safety officers in the United States: Negotiating contradictions between compliance and workplace transformation. Work and Occupations, 48(1), 3-39. https://doi.org/10.1177/0730888420930345

Wand, A. P., Jessop, T., & Peisah, C. (2022). Educating crisis supporters about self-harm and suicide in older adults. The American Journal of Geriatric Psychiatry, 30(11), 1212-1220. https://doi.org/10.1016/j.jagp.2021.10.006 

Westers, N. J., & Plener, P. L. (2020). Managing risk and self-harm: Keeping young people safe. Clinical child psychology and psychiatry, 25(3), 610-624. https://doi.org/10.1177/1359104519895064 

Zarska, A., Barnicot, K., Lavelle, M., Dorey, T., & McCabe, R. (2023). A systematic review of training interventions for emergency department providers and psychosocial interventions delivered by emergency department providers for patients who self-harm. Archives of suicide research, 27(3), 829-850. https://doi.org/10.1080/13811118.2022.2071660  

Table 1: Synthesis Matrix

Table 2: Primary Research Evidence

Table 3: Evidence Summaries