Johnson and
Keeping
the Unit
Delaney
Safe
Original Articles
Keeping the Unit Safe:
A Grounded Theory Study
Mary E. Johnson and Kathleen R. Delaney
BACKGROUND: It is critical for researchers to develop multidimensional models of prevention that reflect the complexity of
the organization of a psychiatric unit. OBJECTIVE: The objective of the study was to develop a midrange theory of violence prevention on inpatient psychiatric units. DESIGN: Grounded theory methods were used for data collection and analysis. Data collection and analyses were conducted simultaneously, and the constant comparative method was used for analysis. RESULTS:
The staff and patients were observed on two inpatient psychiatric units for approximately 400 hours. A total of 28 patients and
staff was interviewed. The basic social process that emerged from the study was Keeping the Unit Safe. The dimensions of this
process are ideology, people, space, and time. CONCLUSION: The findings from this study can be used to assess the safety of
particular units and to identify changes that could potentially influence the outcome of patient and staff safety. J Am Psychiatr
Nurses Assoc, 2006; 12(1), 13-21. DOI: 10.1177/1078390306286440
Keywords: aggression; violence; psychiatric patients; milieu; safety
Aggression and violence on inpatient psychiatric units
have been recognized as significant problems in nursing (Carlsson, Dahlberg, Lützen, & Nystrom, 2004;
Rippon, 2000; Whittington, 2002). Historically, much of
the research in this area has focused on staff and patient characteristics that contribute to aggression and
violence (Johnson, 2004). However, narrowing the
causes of aggression to staff or patient characteristics
has been criticized as too reductive (Duxbury, 2002).
Other researchers have focused on identifying which
patients are at risk for becoming aggressive (Douglas,
Ogloff, & Hart, 2003; Doyle & Dolan, 2002). However,
research related to risk is complicated by the paradox
that predictions of who might become aggressive on
the unit prompt the staff to intervene to prevent the vi-
Mary E. Johnson, RN, PhD, is an associate professor at Rush University College of Nursing, Chicago, Illinois; mary_e_johnson@
rush.edu.
Kathleen R. Delaney, RN, DNSc, is an associate professor at Rush
University College of Nursing, Chicago, Illinois.
The authors acknowledge funding from the National Institute for
Nursing Research (NINR 1R15NR07728-01) and thank Dr. Janice
Swanson for her generous guidance during the development, data
collection, and data analysis of this study and for her helpful critique of an earlier draft of this article.
Copyright © 2006 American Psychiatric Nurses Association
olence, which then proves the predictions wrong (Doyle
& Dolan, 2002). Lastly, researchers and clinicians have
studied the effectiveness of training programs that are
aimed at increasing staff knowledge of de-escalation
skills (Arnetz & Arnetz, 2000; Calabro, Mackey, & Williams, 2002; Morrison & Love, 2003; Needham et al.,
2004). However, these training programs have been
criticized as lacking empirical and theoretical grounding (Morrison & Love, 2003) and for privileging a reactive rather than a proactive stance toward the
management of difficult patients (Delaney, 1994;
Duxbury, 2002).
Despite the large body of research about aggression
and violence on inpatient psychiatric units, there is a
notable lack of theoretical understanding of violence
prevention. Although there have been researchers who
have developed explanatory models of aggression and
violence that take into consideration the interactions
between staff and patients (Duxbury, 2002; Morrison,
1998; Secker et al., 2004), there continues to be a call
for researchers to generate and test multidimensional
models of violence prevention that reflect the complexity of what nurses do on a daily basis to organize and
manage a unit with acutely symptomatic and potentially aggressive patients (Delaney, Pitula, & Perraud,
2000; Duxbury, 2002; Johnson, 2004; Morrison, 1998).
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Johnson and Delaney
STUDY PURPOSE
The purpose of this study was to investigate, using
grounded theory methodology, the day-to-day strategies
that nursing staff use to prevent the behavior of psychiatric patients from escalating to violence. The specific aims
of the study were to (1) identify and describe nursing interventions that were used to de-escalate psychiatric patients who are escalating out of control, (2) describe the
context and conditions under which specific interventions
were used to assist patients to regain control, and (3) construct a substantive theory of the de-escalation process.
In this article, we will present the findings from aim 2—
the contexts and conditions that form the foundation for
the strategies nursing staff use to prevent psychiatric patients’ behavior from escalating to violence.
METHODS
The data collection and analysis were consistent
with grounded theory methods (Chenitz & Swanson,
1986; Glaser, 1978; Glaser & Strauss, 1967; Stern, 1994;
Wilson & Hutchinson, 1991). That is, the theoretical
perspective of symbolic interactionism formed the
foundation for the study (Blumer, 1969), theoretical
sampling was used for participant selection, data were
obtained via participant observation and formal and
informal interviews, data collection and data analysis
were conducted simultaneously, and data were
analyzed using the constant comparative method.
Data Collection
After Institutional Review Board approval was obtained at the study institutions, the investigators first
explained the study purpose to the nursing staff on two
adult locked inpatient psychiatric units that were part
of medium-to-large, not-for-profit medical centers in a
Midwestern city. Both units were general psychiatric
units with a capacity of more than 15 beds and were
short-term stay units.
Data collection began with participant observation
on the two units. On a typical observation day, the
investigator would make herself known to the staff,would
ask a senior staff member how things were going on the
unit, and would find out which patients the staff members
were watching more carefully. If there was a community
meeting, the investigator was introduced to the patients
during the community meeting. Otherwise, the investigator found a strategic place to sit in the dayroom or the hallway, introduced herself to new patients, and took mental
notes of what was happening on the unit. In addition to
signs of escalation such as increased patient agitation or
14
increased disruptiveness, the investigators noted how the
staff responded to the patients,the overall tone on the unit,
the movement of people into and out of the various parts of
the unit, the day-to-day structure on the unit, the day-today activities of the staff, and the day-to-day changes on
the unit. During their time on the unit, the investigators
also informally talked with both patients and staff members about what the investigator saw happening.Together,
the investigators spent a total of approximately 400 hr on
the two units. For consistency, the two investigators divided the two units, with each conducting all the observations on one of the units. Field notes were not taken on the
unit but were written off the unit as soon as possible after
each of the observation sessions. The observation notes
were typed, dated, and entered into the qualitative program Atlas-ti 4.2 (Muhr, 1997) for analysis.
In the initial phase of the formal interviews, the investigators invited staff and patients who met the following
criteria to be interviewed: (1) past involvement in escalating situations, (2) older than the age of 18, (3) able and
willing to talk about their experiences with escalation,
and (4) English speaking. As the study progressed and
the core category was identified, staff and patients were
invited to be interviewed because their knowledge filled
in gaps in the developing categories, helped refine the
emerging ideas,or maximized the range and scope of data
obtained (Chenitz & Swanson, 1986; Cutcliffe, 2000;
Glaser, 1978; Glaser & Strauss, 1967; Hutchinson, 1993).
All of the formal interviews were conducted at a time that
was convenient for the participant and in a place that was
private and free from distractions. After written informed
consent for the interviews was obtained, staff and patient
participants were asked to talk about their experiences
with escalating situations and their thoughts about what
helped patients calm down. As the core category emerged
from the analysis of the data, staff and patients were
asked about what they thought contributed to a feeling of
safety on the unit. Data collection was terminated when
there was informational redundancy, the categories were
saturated, and there were enough data to develop a substantive theory (Hutchinson,1993;Lincoln & Guba,1985;
Morse, 1995). The interviews were tape-recorded and
transcribed verbatim.
Twenty-eight participants were formally interviewed. The participants included 16 staff members
and 12 patients. Five of the staff members were mental
health workers, and 11 were registered nurses. Seven
of the staff members were male, and 9 were female.
Three of the staff participants were nurse managers,
and 13 were direct care staff members. Six of the staff
participants were in their 20s, 2 were in their 30s, 4
were in their 40s, and 4 were older than 50. The staff
tenure on the units ranged from 1 year to more than 15
Journal of the American Psychiatric Nurses Association, Vol. 12, No. 1
Keeping the Unit Safe
years. Five staff members had worked in psychiatry
less than five years, 3 had worked in psychiatry between 5 and 10 years, and 8 had worked in psychiatry
more than 10 years. Two staff members had more than
30 years of experience in psychiatric nursing. Three of
the staff participants (2 nurse managers and 1 per
diem nurse) worked on units that were not one of the
two observation units.
Of the patient participants who were interviewed, 3
were diagnosed with depression, 5 were diagnosed with
schizophrenia, 2 were diagnosed with schizoaffective
disorder, and 2 were diagnosed with bipolar affective
disorder. Six were men and 6 were women. The patients
ranged in age from 22 to 56 years, with an approximate
mean of 33 years. In recruiting patient participants, the
investigators first consulted the staff for patients
whom they thought would be able to tolerate a taped
interview. On the request of the staff, a staff member
first approached two of the identified patients to ask
whether they would be willing to participate in the
study. For the other patients, the investigators approached the patients, explained the study, and asked
whether they would be willing to participate.
Because the majority of the patients on each of the
units were acutely symptomatic, the authors were
careful to recruit patients who not only could fully understand what was being asked of them but could also
tolerate an audio-taped interview. In approaching and
interviewing the patients, the investigators relied on
their many years of experience in psychiatric nursing
to gauge how the patients were tolerating the interviews. One of the patient interviews was terminated
when the patient became agitated, seemed increasingly concerned about the tape recorder, and requested
to stop the interview. The investigator then informed
the staff of the patient’s response to the interview.
Data Analysis
The constant comparative method was used during
all phases of analysis (Charmaz, 2000; Chenitz &
Swanson, 1986; Glaser, 1978; Glaser & Strauss, 1967).
The transcripts from the interviews and the observation notes were entered into the qualitative program,
Atlas-ti 4.2. Initially, the texts from the interviews and
the observation notes were coded line by line to encourage the identification of as many codes as possible. After the initial line-by-line coding, the codes were combined and reduced to form increasingly more abstract
categories. The categories were then coded for their
range, variation, properties, and dimensions. Finally, a
basic social process that represented the main concern
of the staff and the patients was identified (Glaser,
1978). Once this process was identified, the data were
reanalyzed for the causes, contexts, contingencies, consequences, covariances, and conditions that related to
this core category (Glaser, 1978; Swanson, 1986). Although the coding was conducted primarily by one of
the investigators, both of the investigators met regularly during the entire research process to (1) share
ideas about the project as it unfolded, (2) discuss the
emerging codes and categories, (3) identify the tentative characteristics (range, variation, and dimensions)
of the categories, and (4) ensure that the codes and categories were grounded in the data. Throughout the
analysis, both investigators wrote memos that
documented their emerging thoughts and ideas about
the findings.
FINDINGS
In the early phases of the study, our observations
failed to reveal the clear instances of escalation and deescalation we expected. Some of the escalating situations calmed without staff intervention. Other situations remained loud and tense but never intensified to
the point of dangerousness. Other potentially volatile
situations were responded to early on and never escalated. Overall, we found that although the patients
were highly symptomatic, the units remained safe and
relatively calm. As the research progressed, it became
clear to the investigators that the use of de-escalation
strategies was only one aspect of a more complex process. This process, which we identified as Keeping the
Unit Safe, involved (1) individual and milieu strategies
and (2) day-to-day and episodic strategies that were all
directed toward the outcome of keeping the unit safe. In
addition to the strategies used, we found that there
were certain contexts and conditions that underpinned
the organization of care on the unit and were central to
the work of the nursing staff. The following quote from
one of the mental health workers illustrates this
centrality:
We talk a lot about promoting self-efficacy for people,
trying to promote for people that they can do things for
themselves. . . . It’s not perfect but there’s a routine,
there’s regular times for things. . . . For me, I want it to
be a place where people feel like they are physically
safe, where they’re safe in groups to share things, to
talk with us, to be honest about their situation and a
place where they feel like they really can get some kind
of help even if it’s only temporary.
We have organized these contexts and conditions into
four interconnecting dimensions of unit organization—
ideology, people, space, and time (Figure 1). In this arti-
Journal of the American Psychiatric Nurses Association, Vol. 12, No. 1
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Johnson and Delaney
cle, we will describe these four dimensions and will illustrate through the use of the observation and interview data how these dimensions were manifested. The
process of keeping the unit safe and the strategies used
by both staff and patients to keep the unit safe will be
presented in a subsequent article.
Dimensions of Keeping the Unit Safe
Ideology. The belief about the importance of keeping
the unit safe was the ideological position most often articulated by the staff participants. The staff affirmed
that without a safe environment, the patients could not
effectively work on the issues that precipitated their
hospitalization. Thus, the notion of providing a therapeutic environment was closely aligned with the idea of
providing a safe environment. The following quote was
typical of the perspectives voiced by both the direct care
staff and managers:
That’s one of our basic needs just as human beings
[safety]. If you don’t feel safe, there’s no way. . . . How
are you going to feel better if just on a basic level, you’re
afraid? “Oh, man, I might get hit,” or “Somebody might
sneak in my room.” And so that’s why patient safety is
like, at least for nursing staff, . . . our first duty to the
patients. And to make them feel like they’re in a safe
environment.
How the staff responded to the patients also reflected the staff’s beliefs about the causes of a patient’s
escalating behavior. The staff attributed the causes of
escalating behavior to biological, behavioral, or
interactional factors. As such, a patient’s behavior
might be seen as a function of the patient’s illness, a response to anxiety, a way to get attention, or a response
to boredom. These attributions were not rigidly applied
to each patient but rather reflected the staff’s underlying beliefs that (1) similar behavior could have different meanings for different patients and (2) similar behavior could have different meanings for the same
patient at different times. Furthermore, the staff members believed not only that they needed to understand
the meaning of a particular patient’s behavior but also
that the staff members needed to vary their responses
to patients based on the changing understandings of
what might be causing the behavior. The following is a
typical example of how a staff member understood the
meaning of a patient’s behavior. In this situation, the
causal attributions proposed by the staff were not complex psychodynamic interpretations but rather were
grounded in the here-and-now reality of being together
on a psychiatric unit.
16
FIGURE 1. Dimensions of Keeping the Unit Safe
I usually try and talk it out with the person and try and
find out . . . what it is exactly that has set them off or
what’s causing them to get upset. And usually it’s just a
really simple thing that is just a matter of . . . filling out
the menu or needing to do laundry or maybe nobody
had given them the attention or given them the help
with whatever they needed and sometimes that will
cause them to kind of go off.
Lastly, the staff’s ideologies were reflected in the values manifested on the unit. Respect for the person was
a central value that was not only expressed verbally by
the staff members in the interviews but was also revealed through the observations of the staff-patient interactions. The following is from the observation notes:
Throughout the day I [the researcher] observed instances of the non-confrontational and kind way staff
talk to patients. A man comes out of his room after a
bath. He is still quite wet, his gown is on screwy. The
staff member comes up and says, “Let me fix your gown.
You are a little damp here.” The man says “Should I go
back and change?” The staff member replies, “No you
are okay. Let’s just fix this gown.” Never harsh. Always
protecting the patient’s dignity.
People. It is not possible to talk about keeping the
unit safe without taking into consideration the people
on the unit—the staff and the patients. Both the interviews with the staff and the observations on the units
reflected the sense that there was a certain type of patient that was typically admitted to the unit. Over time,
the staff developed a culture for organizing the care of
Journal of the American Psychiatric Nurses Association, Vol. 12, No. 1
Keeping the Unit Safe
patients who are admitted to the unit—“This is how we
do things here.” This consistency in the type of patient
who is admitted increased the staff’s sense of predictability and safety on the unit.
However, because of the economic realities of filling
the beds and the limits to how much control the staff
has over who is admitted, there were times when patients who were not seen as typical for the unit (e.g., patients with substance abuse problems, patients from
the criminal justice system, patients who are developmentally delayed) were admitted. The challenges presented by the admission of these patients ranged from
the sense that staff was not as effective working with a
particular type of patient to more serious concerns
about the overall safety of the unit. The following is an
example from an interview with a nurse manager
about the admission of a patient who presented serious
concerns about safety on the unit:
After the incident happened, the staff did a debriefing
with the patients. One of the patients . . . said, “If you
are going to have patients like that man on this unit,
you need goons. None of us felt safe with that guy here,
’cause you don’t have the right kind of [staff]. He [the
other patient] was looking around and knew that he
could pick any one of you off any time he wanted to. And
he knew that. He knew that you couldn’t contain him.”
Lastly, the interviews and observations revealed
that keeping the unit safe was not merely a function of
the number of patients and the number of staff members on the unit. Staffing ratios alone did not determine
whether the unit was safe. Rather, the mix of staff
members in relation to the mix of patients determined
safety on the unit. Although the two study units had
very different staffing ratios, both units had few episodes of aggression and violence. The unit with higher
patient-to-staff ratios tended to have a more seasoned
staff and to admit patients who were well known to the
staff. Because several of the staff members had worked
on the particular unit many years and because of multiple hospitalizations for some of the patients, the staff
knew the patients well and reacted less quickly to behavior that the uninformed observer might see as escalating out of control. The seasoned staff knew which behavior would escalate to violence and which behavior
would resolve on its own or with relatively subtle
interventions.
Space. It was clear from the observations and the interviews that a primary purpose of the inpatient unit
was to provide a safe space for the patients and staff. To
promote safety, maintaining visibility was one of the
salient conditions for keeping the unit safe. Yet, maintaining visibility was challenging because the size and
shape of the units were determined not simply by the
need to increase visibility but also by the shape of the
hospital itself and the need to accommodate a certain
number of patients. To compensate for less-than-ideal
spaces, the staff deliberately decided when to open up
and close off parts of the space, how to situate people
within the space, and how to regulate the flow of people
into and out of parts of the space. Although the patients
did not spontaneously talk about what helped them
feel safe on the unit, they did talk about other settings
in which they did not feel safe and, when asked, were
able to articulate what contributed to their feeling safe
on the unit in which they were now hospitalized. In this
next quotation, the patient responded to the question
“What helps you feel safe on the unit” and highlighted
the importance of having staff present and visible to
patients:
One thing is the set-up. They keep somebody [staff] in
the corner and they keep somebody [staff] down at one
end and there’s usually somebody [staff] walking
around. So as far as my physical safety goes, I feel
pretty safe.
The following manager worked on a unit that had
been designed as a psychiatric unit. It was clear from
her description that visibility was an important consideration when designing the shape of the unit:
The station is open in the middle and there are three
halls and you can see down each [hall]. And the great
room where they eat, gather, whatever, is right in front
of the nurses’ station, all open . . . everything can be observed. . . . They [the staff] can see and hear everything,
which helps.
Proximity was another spatial condition that contributed to keeping the unit safe. Regardless of the size
of the unit, the proximity of one section of the unit to another made it either easier or more difficult for staff to
see and hear what was happening on the unit. Visibility was decreased when the nurses’ station and
dayroom were not situated in close proximity. Safety
was decreased when patients’ rooms were in close proximity to the exit doors. Oddly shaped or large units
were more likely to have nooks and crannies in which
patients could hide. Or there might be hidden spaces on
the unit that reduced visibility and made monitoring
the patients more difficult. As an example, the following is an excerpt from one of the observation notes:
They [the patients] go in the smoking room. The nurse
says to another staff member, “What do you think?
Should we lock the room?” She says, “Well, you can see
Journal of the American Psychiatric Nurses Association, Vol. 12, No. 1
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Johnson and Delaney
in from the nurses’ station. But when the lights go
down at 8:00 we will have to lock that door and keep
them out.” I mention to one of the staff that two weeks
ago when the patient was going after another patient,
she would be in a corner of the smoking room where no
one could see her.
Although large spaces reduced the visibility of parts
of the unit, large spaces also gave the patients and staff
greater space in which to move around. Large spaces
gave the patients more space to pace in and more space
in which to establish a sense of personal boundaries.
Whereas large spaces made it difficult for staff to hear
trouble brewing, large spaces were also less crowded
and less noisy. Because some patients need more physical space than other patients, one of the critical features of keeping the unit safe was not simply the size
and shape of the space but the size and shape of the
space in relation to the population of patients and the
number of people on the unit. The relationship between
the size of the space and the number of people is exemplified by one of the direct care staff members who
talked about the impact of an increase in both the number of patients and the number of staff on the unit:
Our numbers have increased . . . we got more staff, too.
So we’ve now got students and residents and nurses
that we didn’t have. So, there’s just so many people
here. The noise level has become more difficult, I think.
. . . One thing I’ve always liked about this unit is that it’s
big, with a lot of space. And if someone’s going to be
loud, you’re not surrounded by 50 thousand people
packed in. You can spread it out. That’s just getting
harder to do now.
The last salient spatial condition was the division of
space into private and public space. Boundaries—both
tangible and intangible—not only divided the public
and private space but were also critical in keeping the
unit safe. The boundary between the units and the rest
of the world was demarcated by the locked doors.
Within the units, certain sections—such as the medication room, the utility rooms, the nurses’ station and
sometimes the kitchen area—were also closed off by
locked doors.
In addition to these tangible boundaries, the intangible boundaries on the units were reinforced by the
rules on the unit. For instance, patients were prohibited from going into each other’s rooms and were prohibited from touching each other. Some of the patients
were also prohibited from borrowing and lending personal items. Certain items were prohibited from being
brought onto the unit. As with the tangible boundaries,
these intangible boundaries were critical to maintain18
ing a sense of safety on the unit. The following is from a
direct care staff member who talked about the rule that
regulated patient-to-patient physical contact:
See that’s another thing when you say touching. Because it is a few people [new patients] that have been
through here that virtually sees nothing wrong with
touching. But like I try to tell them, everybody does not
like to be touched without their permission being given.
. . . We try not to have patients touching at all, you know
walking down the hall holding hands, giving each other
a hug every morning. If you want to do that upon discharge, fine but we try to discourage it from a daily
thing.
Time. The study units were clearly organized around
time. Staff and patient activities occurred during the
same time each week. The staff worked during a designated shift and for a designated number of hours. The
patients were admitted during a particular point in
their illness trajectory and were hospitalized for a particular length of time. Staff members were employed on
the unit at a particular point in their career trajectory
and stayed employed on that unit for a particular
length of time. On a typical day, the staff and patients
knew which activity would follow the previous activity.
For the most part, the staff members and patients came
to know each other over time and to know that certain
behaviors would result in particular responses. The organization of time gave structure to the day, which in
turn contributed to a sense of consistency and predictability on the unit.
By contrast, the staff often did not know when patients would be admitted and discharged, nor could the
staff predict the patients’ behavior at various phases of
the illness trajectory. More important, at any given moment, there was the looming possibility that things
might not go as expected. The reality of inpatient psychiatric units is that there are many conditions that
cannot be known and anticipated in advance. For example, at any given moment and for reasons that may
not always be clear, the milieu would erupt into a
frenzy. After a patient was admitted to the unit, the status and behavior of the patient and the trajectory of the
hospitalization were often uncertain and variable.
Newly admitted patients could be unpredictable simply because they were unknown to the staff. But known
patients could also be unpredictable because of
changes in behavior from one hospitalization to the
next. As an example, the following quote is from one of
the direct care staff members who talked about the
difference in one patient’s behavior:
That’s another one that I know from previous hospitalization, and this year’s hospitalization is a little bit dif-
Journal of the American Psychiatric Nurses Association, Vol. 12, No. 1
Keeping the Unit Safe
ferent. Last time she was more trustworthy with me. I
could get her to respond to my cues more readily than
most of the other employees. This time I’m on the opposite side. Racial slurs, paranoia, delusions. Like right
now—this time I actually feel like I’m one of the new
staff as far as trying to control her this time around.
Although an individual patient’s behavior was often
uncertain and variable, the impact of a patient’s behavior on the milieu was even less predictable. An agitated,
angry, aggressive, or provocative patient could quickly
change the entire tone of the milieu. And yet, on the
next shift or the next day, the tone of the milieu—even
with the same patients—could be entirely different.
Moreover, milieu interventions might be effective with
one group of patients and ineffective with another
group.
Overall, predictability was enhanced when patterns
could be identified, when the staff and patients were
known to each other and communicated with each
other, and when there was structure and consistency in
the interactions between the staff and patients. Predictability was diminished when the staff worked with
staff members who were unfamiliar with the unit or
new to the unit. An individual staff member’s ability to
anticipate how things might progress and which interventions might work was diminished when that person
worked fewer days in a row or floated to unfamiliar
units. In these unfamiliar circumstances, direct care
staff found it harder to identify patterns and to “get a
feel” for the patients and the milieu. As an example, the
per diem nurse who was interviewed talked about why
she did not feel safe when she worked at a hospital that
had not been part of the observation portion of the study:
There were four units and I was a PRN so I would shuffle to all the different units and many of the other people were, too. So, there wasn’t a consistent staff that
knew the patients and the patients knew them. That
was a real important piece. There might be two to three
people floating on any given unit. It’s bad enough for
the staff to not know the patients, but it must be frightening for the patients to not know the staff. . . . I often
worked weekends and if they had a sick call, they would
fill in where they could. Of all the units, it was most
striking for me on the geriatric unit. If I knew people’s
routines, I was better and I think they felt safer with me
if they knew me.
DISCUSSION
Although individual assessments and interventions
are important strategies for managing aggression and
violence, the findings from this study highlight the relationship between the organization and structure of
the unit and the prevention of violence—a relationship
that has been taken for granted and consequently overlooked by researchers. Whereas there have been studies
of individual risk factors for and prediction of violence
(Abderhalden et al., 2004; Douglas et al., 2003; Haim,
Rabinowitz, Lereya, & Fennig, 2002; Harris & Rice,
1997), the findings from this study suggest a proactive,
milieu approach to reducing risk and enhancing predictability. These findings suggest that predictability is
augmented when the staff has more experience—on
the unit and in psychiatry; when the staff has greater
knowledge—of the patient, self, other staff members
and of psychiatric interventions; with structure and
consistency—with individual patients and in the milieu; and when staff members understand and recognize patients’ patterns of behavior.
These findings suggest that risk is reduced by the effective use of space—that is, enhancing visibility and
enforcing the boundaries between public and private
space, by staff being present and monitoring patients,
by managers attending to the mix of patients and staff,
and by establishing and enforcing rules related to the
use of space. In addition to reducing risk and enhancing
predictability through the organization of the space,
time, and people on the unit, the direct care staff and
managers also voiced (and practiced) an ideology that
supported safety, respect for the person, tolerance of behavior, and the need to understand the meaning behind
the behavior. Although the staff members strove to increase predictability, they also were attuned to the tension between predictability and control. The staff and
managers voiced a desire to adopt an ideological stance
that balanced flexibility with the need to enhance
predictability.
RECOMMENDATIONS
Research
It is clear from this study that keeping the unit safe
is a complex, dynamic process that is underrated and
understudied. The lack of research evidence hampers
nurses and managers from effectively making the case
that better staffing, more nurses, a different mix of patients, better facilities, and more control over who is admitted are needed to keep the unit safe. Little is known
about the impact of staffing on aggression and violence.
Little is known about how different types of spaces contribute to aggression and violence and which patients
calm or become more agitated in different spaces. And
little is known about the impact of structure and consistency on aggression and violence. The four dimensions presented in this article could provide the frame-
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19
Johnson and Delaney
work for further investigation about the relationships
among these administratively mediated variables and
the outcome of aggression and violence.
For this study, the observations were conducted on
two general adult psychiatric units. Although we would
propose that the dimensions would hold true for other
types of psychiatric units, the interaction of the variables and their relation to safety might vary. Further
research is needed to determine which interactional
variables contribute to reduced aggression and violence on different types of units and how well the conditions within these dimensions predict important outcomes such as aggression and violence and the
perception of feeling safe on the unit.
Lastly, although one of the participants in this study
was asked to talk about what contributed to her not
feeling safe on the unit, it would be helpful to the development of the science to have a greater understanding
from the perspective of both patients and staff about
what contributes to their not feeling safe on psychiatric
units. In addition to objective measures of safety, such
as lack of injury, there also appears to be a subjective
feeling of safety. Little is known about the relationship
between this subjective notion of safety and the
creation of a therapeutic milieu.
Practice
Until we have more research, however, this multidimensional framework can serve as a starting point for
staff nurses and managers to evaluate the state of their
units. This framework provides evidence of the complexity involved in keeping the unit safe and can be
used as a starting point for nurses to take back, in a setting in which they have lost it, control of their practice.
The following questions could be used by staff to begin
the evaluation process and to identify areas for discussion, education, or change.
Ideology
• What are the values on the unit? Where do the values originate? To what extent are staff members in
agreement about the values?
• How important is safety as a value and how is this
value manifested?
• What are the staff beliefs about the cause and meaning of particular behaviors?
• What are the staff members’s beliefs about how they
should treat patients with psychiatric illnesses? Are
the beliefs consistent among the staff members?
People
• Patients: What is the typical patient on the unit?
How many high-risk patients are admitted to the
unit? What is the mix of patients on the unit? How
20
much control does staff have in terms of who is admitted to the unit?
• Staff: What is the mix of staff on the unit (professional/
nonprofessional)? Does the skill mix of the staff
match the mix of patients on the unit? Does staff have
the ability to increase or decrease staffing based on
the changing needs of the unit?
Space
• How large or small is the space in relation to the
number and types of patients on the unit? Is the
space crowded? Is the space noisy?
• How is the visibility on the unit? Are there parts of
the space that are not easily visible to staff? What is
the proximity of the nurses’ station to the dayroom?
What is the proximity of the nurses’ station to the
patient rooms? Do these proximities enhance or diminish visibility? Is there a way to structure the
space to increase visibility on the unit?
• Where do the staff members situate themselves in
the space? How many staff members are present in
the milieu?
• What is the division between private and public
space? Do patients have their own space? Is the private space appropriate to the population? In other
words, are private rooms available for patients who
need private rooms? Do the patients who need to
pace have enough space to do so?
• What are the procedures for ensuring that boundaries are maintained?
Time
• Staffing: How much experience do staff members
have working with psychiatric patients and working
on the particular unit? Does the unit have a core of
seasoned staff members? Are there consistent staff
members on the unit and on particular shifts? Is
there a cohort of staff members who have experience
working with each other?
• Patients: What is the average length of stay? Do
staff members have time to get to know patients, or
is the turnover rapid? How frequently are patients
readmitted? What is the pace of admissions and discharges? Do staff members have any control over
the timing of admissions and discharges? How much
predictability is there in terms of when patients are
admitted and discharged? How predictable are patient’s patterns of behavior?
• Milieu management: Are the structure and programming on the unit appropriate to the patient
population? How frequently do staff members monitor individual patients and the milieu? Is there a
predictable pattern to the pace, tone, noise, and activity level on the unit?
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