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To date, psychological theories of aggression have shown limited applicability to the first-hand experience of real-world violence. Examining the experiences of those directly involved in violent offending, may enable professionals to develop a strengthened and more refined understanding. The current study aimed to develop a theoretical model of offender experiences of decision-making, during the commission of a violent offence. The Critical Decision Method (CDM) for cognitive task analysis was conducted within a British prison, with nine participants who had been convicted of a serious violent offence. Interview transcripts were analysed using constructivist Grounded Theory (CGT). Seven themes were interpreted from participant narratives: (i) predisposing influences, (ii) environment, (iii) emotion, (iv) triggering events, (v) decision to act, (vi) identity and (vii) severity of harm caused to the victim. Participants' narratives were found to focus upon a process of decision-making which followed a sequence of events, from the impact of early experiences, through to the in-the-moment decisions, that led to acting in a violent manner. This study provides novel insights into the experience of violent decision-making. Participants emphasised the role of emotion and identity. A range of clinical implications are discussed which highlight the important role of emotion regulation and identity transformation in the rehabilitation of violent offenders. [ABSTRACT FROM AUTHOR]

Accessible Summary: What is known on the subject?: Emergency departments (ED) are key settings to support and manage suicidal crisis; thus, ED staff are often the first point of contact for people in suicidal crisis. Despite this, some ED staff receive little training and/or education on how to best support such patients. What the paper adds to existing knowledge: Previous research focuses on one staffing role (e.g. triage nurses) whereas this paper includes staff working across the ED pathway. Administrative staff have often been excluded from research, despite representing a key part of the clinical pathway and being a person's initial contact with the ED.Overall findings demonstrate that staff experience a lack of confidence, training and burnout due to regularly supporting people in suicidal crisis. Staff also perceive there to be a negative ED culture, which often leads to poor attitudes towards suicidal crisis. The main challenges reported are an increase in working pressures, unavailability of resources and staff retention.Findings build upon previous research to highlight key challenges different staff face along the clinical pathway and the implications this can have on a patient's journey and follow‐up care provided. What are the implications for practice?: Findings are of particular importance and relevance to ED managers, and more broadly NHS England. Negative ED culture, poor staff attitudes and confidence can have a detrimental impact on both staff health and wellbeing, as well as a patient's journey throughout the ED, resulting in repeat presentations and absconding as appropriate support is not received.Policymakers need to consider staff burnout and lack of resources in mental health care strategies, and training programmes should be developed to improve culture and confidence among ED staff and managers to improve care for people attending EDs in suicidal crisis. Introduction: Emergency departments (EDs) are often the first point of contact for people in suicidal crisis. Yet, previous work has tended to focus on only one type of staffing role, failing to account for different staff perspectives along the clinical pathway. Aims: To explore and synthesise the perspectives of ED administrative (i.e. receptionists), medical (triage nurses) and mental health staff (liaison psychiatrists) working with people presenting in suicidal crisis. Method: Qualitative study guided by thematic analysis of semi‐structured interviews with 23 ED staff across six EDs in Cheshire and Merseyside, England. Results: Findings demonstrate that staff experience a lack of confidence, training and burnout due to regularly supporting people in suicidal crisis. The main challenges reported are an increase in working pressures, unavailability of resources and staff retention. Discussion: Staff felt unequipped to deal with suicide‐related presentations. Organisational support is perceived to be lacking, with increased staffing pressures and poor service availability. This lack of support was linked to job dissatisfaction. Implications for Practice: Findings are of particular relevance to individual EDs and NHS England. Addressing the challenges staff are reporting can have positive implications for staff wellbeing, as well as a patient's experience and journey throughout the ED. [ABSTRACT FROM AUTHOR]

Accessible Summary: What the paper adds to existing knowledge?: Personality disorder is a serious mental health condition affecting up to 52% of psychiatric outpatients and 70% of inpatients and forensic patients. People with a diagnosis of personality disorder have higher morbidity and mortality than those without.Service users and carers reported a lack of training for staff in the management of individuals with a diagnosis of personality disorder, particularly with regard to self‐harm and suicidal behaviours.Staff burnout creates barriers to compassionate person‐centred care for individuals with a diagnosis of personality disorder as staff struggled to accommodate the nature of the presentation when under significant emotional, psychological and professional strain caused by understaffing and lack of support. What are the implications for practice?: This paper adds new knowledge by informing services of ways to improve care provision from the perspectives of both carers and service users.A more holistic and less medicalised approach to the treatment of problems associated with a diagnosis of a personality disorder should be adopted, and personality disorder training introduced for all healthcare practitioners, to improve patient outcomes. Introduction: There is limited understanding of the experience of people with complex mental health (CMH) needs, including those with a diagnosis of personality disorder (PD) and carers of those individuals. Little is known about carers of those in inpatient forensic settings, yet it has been identified that they may have additional needs when compared to general carers. Research highlights that community carer support services were perceived as inadequate and out‐of‐area placements were described as putting an added strain on ability to support loved ones. Understanding PD within a population of people with CMH needs and how a diagnosis described as PD impacts on care and treatment experience is vital to providing high‐quality care. Aim: To evaluate the care experience of service users and carers with lived experience of a diagnosis of PD and out‐of‐area placements. Method: Semi‐structured interviews were conducted with six service users and four carers to explore the experiences and perspectives of people with a diagnosis of PD. Interviews were audio recorded and thematically analysed. Results: Four interrelated themes were developed; Influence of a diagnosis of PD on Staff, Early and Appropriate Intervention, Recognition of the Individual and Training and Knowledge of people with a diagnosis of PD. Discussion: Anti‐stigma interventions for staff, research on care provision and structural changes to services including more evidence‐based therapy for individuals with a diagnosis of PD may help reduce disparate treatment and improve prognosis for recovery. Implications for Practice: This paper informs services of ways to improve care provision from the perspective of carers and service users. A more holistic and less medicalised approach to the treatment of problems associated with diagnoses of PD should be adopted, and PD training for all healthcare practitioners to improve patient outcomes. [ABSTRACT FROM AUTHOR]

The Dynamic Appraisal of Situational Aggression (DASA) provides a quick and systematic assessment of short-term violence risk. Risk assessment should be closely aligned to management and result in interventions aimed to reduce risk. The aim of this study was to investigate what interventions followed a moderate/high DASA score and whether they reduced risk. The impact of staff training was also assessed. The study was a retrospective analysis of health records within a medium secure hospital over 6 months. Data was gathered on tool adherence and interventions that were used to reduce risk following a moderate/high score. The change in DASA score following the intervention was recorded. There were 70 patients covering 8224 bed days. There were 24 occasions where a moderate score led to an intervention (n = 24/40%), and 26 occasions for a high score (n = 26/87%). A moderate score was mostly followed by no intervention (n = 35/59%), a high score was mostly followed by seclusion (n = 9/29%). The intervention that led to the largest reduction in DASA score was pro re nata medication following a moderate score and seclusion following a high score. The training of staff led to a reduction in tool adherence and increased intervention use. These results support the need for combining the DASA assessment with operationalised systems to link assessment with risk prevention to help reduce aggression and restrictive practices. [ABSTRACT FROM AUTHOR]

SUMMARY: Risk assessment in clinical practice is often characterised as a process of analysing information so as to make a judgement about the likelihood of harmful behaviour occurring in the future. However, this characterisation is brought into question when the evidence does not support the current use of risk assessment approaches to predict, or provide probability estimates of, future behaviour in a way that is usable in single instances arising in individual cases. This article sets out a broader and more clinically applicable description of risk assessment which takes account of the wider influences on how this clinical activity takes place. In so doing, it provides a framework to guide clinicians, researchers and authors of practice guidance who are interested in improving approaches to risk assessment. [ABSTRACT FROM AUTHOR]

Emergency department (ED) staff are often the first point of contact for individuals in suicidal crisis. Despite this, there is no published research systematically examining the factors influencing decision-making for this patient group. MedLine, CINAHL, PsycINFO, Web of Science and Cochrane Library databases were searched for three key concepts: (1) suicide, (2) accident and emergency department and (3) decision-making. Three reviewers screened titles, abstracts and full papers independently against the eligibility criteria. Data synthesis was achieved by extracting and analyzing study characteristics and findings. The Mixed Methods Appraisal Tool (MMAT) was used to assess the quality of included studies. Seventeen studies met the eligibility criteria and were included in this systematic review. Studies were published from 2004 to 2020 and were of good methodological quality. A number of patient (method of self-harm, age, gender), contextual (availability of services and staff) and staff-related factors (attitudes, training, knowledge) were reported to influence decision-making for patients in suicidal crisis presenting to EDs. Decision-making in the ED is complex and is influenced by patient, contextual and staff-related factors. These decisions can have an impact on the future care and clinical pathways of patients in suicidal crisis. Additional training is needed for ED staff specifically related to suicide prevention. [ABSTRACT FROM AUTHOR]

Objective: Crisis lines are the first mental health service contact point for many people, making them a vital community and public health intervention. Given the current and potential utility of crisis lines, better understanding the characteristics, socioeconomic factors and subsequent referral pathways of callers is critical to identifying targeted ways to improve such services. Study Design: The dataset captured calls to the Cheshire & Wirral Partnership NHS Foundation Trust (CWP) crisis line between August 2020 and August 2021. Calls were examined if self-harm, risk to self, or overdose were reported by the caller. Descriptive analyses were conducted to produce a clinical and demographic profile of the callers using the crisis line. Results: Call handlers were significantly more likely to call 999, hand over to a practitioner and less likely to provide advice and guidance if self-harm, risk to self or overdose was reported. Social issues were found to be significantly associated with all 3 outcomes: self-harm, risk to self and overdose. Conclusion: The current study provides the first exploratory analysis of the socioeconomic factors and resultant care pathways for those contacting a UK crisis line service. The findings have important implications for community early intervention efforts to reduce self-harm and suicidal behaviours. [ABSTRACT FROM AUTHOR]

To improve the safety of healthcare systems, it is necessary to understand harm-related events that occur in these systems. In mental health services, particular attention is paid to harm arising from the actions of patients against themselves or others. The primary intention of examining these adverse events is to inform changes to care provision so as to reduce the likelihood of the recurrence of such events. The predominant approach to investigating adverse incidents has relied on the cause-and-effect conceptualisation of past events. Whilst the merits of approaches which are reliant on cause-and-effect narratives have been questioned, alternatives models to explain adverse incidents in health settings have not been theoretically or empirically tested. This novel article (i) examines the notion of causation (and the related notion of omission) in the context of explaining adverse events in mental health settings, and (ii) draws on a long-established discipline devoted to the study of how the past is interpreted (namely historiography) to theoretically investigate the innovative application of two historiographical approaches (i.e. counterfactual analysis and historical materialism) to understanding adverse events in mental health settings. [ABSTRACT FROM AUTHOR]

Secure mental health services aim to assess and treat mentally disordered offenders, where a patients care pathway involves their movement from service to service on an individual journey towards recovery. Research has attempted to understand the relationship between psychosis and violence for mentally disordered offenders. From this empirical evidence base a tripartite typology has emerged. Three subgroups have been categorised as (i) schizophrenia preceded by conduct disorder (SZ+CD), (ii) offenders with schizophrenia who begin offending at illness onset (SZ+AS), and (iii) offenders with schizophrenia (SZ). This study aimed to examine differences in care pathways between subgroups. The sample consisted of 77 male patients admitted to low- and medium-secure care. The subgroup of patients was determined from data collected from health records. The analysis examined the differences in patient care pathways. The results demonstrated differences in subgroup pathways to, within and from secure services. The SZ+CD subgroup had a higher number of placements used, were more likely to transition between the same level of security, and had an increased use of the private sector. The SZ+AS subgroup was significantly more likely to use intensive care and less likely to use high secure services. Examining care pathways of mentally disordered offenders will ensure a more evidence-based approach to the configuration and operationalisation of services, help guide policymakers and hopefully improve patient care. [ABSTRACT FROM AUTHOR]