Abstract
Background: Violence and aggression within inpatient psychiatric units is a serious problem affecting not only staff and patient safety, but the effectiveness of patient care. It is important that methods are found to effectively diffuse the imminent risk of violence in advance within psychiatric inpatient units. Relational security is a preventative measure integral to providing staff and patient safety in inpatient settings. Unfortunately, the current lack of clarity around relational security is undermining its application and limiting its use.
Objective: The aims of this integrative review are to:
1. Develop a clear working definition of relational security
2. Establish a framework to describe the core components of relational security and their relationship to each other
3. Assess which components of relational security have the strongest evidence for being effective in violence prevention
Methodology: A systematic search process was utilised to identify relevant primary data for this integrative review. Electronic databases PsychINFO, Ovid MEDLINE and Embase were searched using the terms 'aggression', 'violence', 'inpatient', 'mental disorder', 'aggression management' and 'psychiatry'. Due to the limited number of citations produced using the search term 'relational security', this term was removed from the final selection of search terms. Titles were then scanned, and abstracts read of relevant topics. Forty-eight full text articles were read, 17 of which, met criteria for further analysis. The final selection was then appraised for quality using the Joanna Briggs Institution quality assessment tools. Data from the studies was extracted and themes were drawn from the primary data.
Summary: The three key themes were obtained from the synthesis were: therapeutic relationship, ward climate and team dynamics. Each of these played a key role in the implementation of relational security, contributing to interpersonal safety within psychiatric inpatient settings. The findings also provided evidence for a proposed new definition of relational security which highlighted the importance of clinical knowledge of the patient, the patient mix and therapeutic programme, and communication within the clinical team.
A number of areas for further research were identified. There is a need for further qualitative research within the parameters of relational security, looking in depth at staff and patient perspectives regarding violence and its management through unstructured interviews and focus groups. There is also a need for quantitative data, measuring the impact of relational security measures on inpatient violence, isolating key elements within the relational security construct.