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The aim of this project is to evaluate the violence prevention method Therapeutic meeting with aggression (TERMA) regarding adverse events and perceived safety by patients and staff within forensic psychiatric inpatient care. Additionally, the project will investigate whether the organizational culture influences the implementation of the TERMA method and the experiences of patients and staff in situations involving threats, violence, and the use of coercive measures.
Overall aim The aim of this project is to evaluate the violence prevention method Therapeutic meeting with aggression (TERMA) regarding adverse events and perceived safety by patients and staff within forensic psychiatric inpatient care. Additionally, the project will investigate whether the organizational culture influences the implementation of the TERMA method and the experiences of patients and staff in situations involving threats, violence, and the use of coercive measures.
Research questions
Forensic psychiatric patients are a heterogeneous group, given their various psycho pathologies, criminal histories and risk factors for reoffending. Patients sentenced to forensic psychiatric care are under involuntary care for long periods of time and rehabilitation length of 5-6 years are not unusual. Aggressive and violent behavior among patients is a prevalent occurrence in forensic psychiatry and a hindrance for successful rehabilitation. The complex composition of mental illnesses contributes to an experience of an insecure environment for both patients and healthcare personnel.
There is a need for research on the content and effects of managing aggression and violence. Several methods have been developed to manage and prevent such behaviors. One such method is the Therapeutic Meeting with Aggression (TERMA). It has previously been implemented in inpatient forensic psychiatric care in Sweden but further research is needed in evaluating its usefulness.
Therapeutic meeting with aggression (TERMA) TERMA was developed from the Norwegian Bergen model, with modifications made to align with the Swedish healthcare and legal systems. The primary aim of TERMA is to prevent aggression and violence through a system of low-effective treatment that is divided into escalating levels based on the patient's aggression level, risk of violence, and acts of violence. The TERMA model focuses on treatment, communication, and management of compassionate healthcare in forensic psychiatric settings. The levels of the TERMA model are in a "cascading" order, whereby if the treatment and management of one level are ineffective, the next level is initiated, and so on. The primary level involves the daily behavior and health status of the patient. The secondary level involves risk assessment and violence management, with a focus on creating an understanding of the situation for both the patient and healthcare workers. The tertiary level is utilized when violence cannot be avoided. Each level corresponds to a specific response according to the demands of the situation and environment.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Staff | Educational intervention in TERMA. All staff are required to attend the education. |
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| Patients | Patients will not attend any education in TERMA. Data will be collected before and after the staffs education to se if the patients think the attitude of the staff have changed. |
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| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Education in TERMA | Behavioral | Education of staff in TERMA. The primary aim of TERMA is to prevent aggression and violence through a system of low-effective treatment that is divided into escalating levels based on the patient's aggression level, risk of violence, and acts of violence . The TERMA model focuses on treatment, communication, and management of compassionate healthcare in forensic psychiatric settings . The levels of the TERMA model are in a "cascading" order, whereby if the treatment and management of one level are ineffective, the next level is initiated, and so on. The primary level involves the daily behavior and health status of the patient. The secondary level involves risk assessment and violence management, with a focus on creating an understanding of the situation for both the patient and healthcare workers. The tertiary level is utilized when violence cannot be avoided . Each level corresponds to a specific response according to the demands of the situation and environment. |
| Measure | Description | Time Frame |
|---|---|---|
| Perceived Safety Questionnaire (E13) | Questionnaire data on perceived safety. E13 measures factors such as self-estimated safety, feeling of safety, acts of violence and coercion, reaction and aggression measurements and cause of aggression in the wards. The questionnaire consists of 13 statements whose agreement is answered on a four-point Likert scale from completely agree to completely disagree. Minimum value=13, maximum value=52, higher values means better outcome. | Change measure (baseline to 6 months) |
| Perceived Safety Questionnaire (E13) | Questionnaire data on perceived safety. E13 measures factors such as self-estimated safety, feeling of safety, acts of violence and coercion, reaction and aggression measurements and cause of aggression in the wards. The questionnaire consists of 13 statements whose agreement is answered on a four-point Likert scale from completely agree to completely disagree. Minimum value=13, maximum value=52, higher values means better outcome. | Change measure (baseline to 1 year) |
| Measure | Description | Time Frame |
|---|---|---|
| Organisations Value Questionnaire (OVQ). | Questionnaire data on organizational culture. OVQ is used to measure the the overall organizational culture and dimensions human relation (HR), open systems (OS), rational goal (RG) and internal process (IP). It consisted of 52 items with alternative answers of the Likert type ranging from "strongly disagree" to "strongly agree". Averages were calculated for the total OVQ and for each subscale; a high score indicates strong disagreement. Minimum value 52, maximum value 520 for the total OVQ. Minimum value 13, maximum value 130 for each of the subscales. |
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Inclusion Criteria Staff:
Exclusion Criteria Staff:
Inclusion Criteria Patients:
Exclusion Criteria Patients:
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Staff at a forensic psychiatry department. Patients at a forensic psychiatry departmen
| Name | Role | Phone | Extension | |
|---|---|---|---|---|
| Sara Wallström, PhD | Contact | 0701-714468 | sara.wallstrom@vgregion.se |
| Name | Affiliation | Role |
|---|---|---|
| Sara Wallström, PhD | Västra Götalandsregionen | Principal Investigator |
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No plan to share individual participant data (IPD)
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| ID | Term |
|---|---|
| D004522 | Educational Status |
| ID | Term |
|---|---|
| D012959 | Socioeconomic Factors |
| D011154 | Population Characteristics |
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| Changed work routines based on TERMA | Other | NO planned intervention but staff work routines and behavior may change after their education in TERMA. Patients are exposed to these changes. |
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| Change measure (baseline to 6 months) |
| Organisations Value Questionnaire (OVQ). | Questionnaire data on organizational culture. OVQ is used to measure the the overall organizational culture and dimensions human relation (HR), open systems (OS), rational goal (RG) and internal process (IP). It consisted of 52 items with alternative answers of the Likert type ranging from "strongly disagree" to "strongly agree". Averages were calculated for the total OVQ and for each subscale; a high score indicates strong disagreement. Minimum value 52, maximum value 520 for the total OVQ. Minimum value 13, maximum value 130 for each of the subscales. | Change measure (baseline to 1 year) |
| Organisations Value Questionnaire (OVQ)_Safety Questionnaire (E13) | Correlation between organizational culture and perceived safety. OVQ is used to measure the the overall organizational culture and dimensions human relation (HR), open systems (OS), rational goal (RG) and internal process (IP). It consisted of 52 items with alternative answers of the Likert type ranging from "strongly disagree" to "strongly agree". Averages were calculated for the total OVQ and for each subscale; a high score indicates strong disagreement. Minimum value 52, maximum value 520 for the total OVQ. Minimum value 13, maximum value 130 for each of the subscales. E13 measures factors such as self-estimated safety, feeling of safety, acts of violence and coercion, reaction and aggression measurements and cause of aggression in the wards. The questionnaire consists of 13 statements whose agreement is answered on a four-point Likert scale from completely agree to completely disagree. Minimum value=13, maximum value=52, higher values means better outcome. | Baseline |
| Organisations Value Questionnaire (OVQ)_Safety Questionnaire (E13) | Correlation between organizational culture and perceived safety. OVQ is used to measure the the overall organizational culture and dimensions human relation (HR), open systems (OS), rational goal (RG) and internal process (IP). It consisted of 52 items with alternative answers of the Likert type ranging from "strongly disagree" to "strongly agree". Averages were calculated for the total OVQ and for each subscale; a high score indicates strong disagreement. Minimum value 52, maximum value 520 for the total OVQ. Minimum value 13, maximum value 130 for each of the subscales. E13 measures factors such as self-estimated safety, feeling of safety, acts of violence and coercion, reaction and aggression measurements and cause of aggression in the wards. The questionnaire consists of 13 statements whose agreement is answered on a four-point Likert scale from completely agree to completely disagree. Minimum value=13, maximum value=52, higher values means better outcome. | 6 months |
| Organisations Value Questionnaire (OVQ)_Safety Questionnaire (E13) | Correlation between organizational culture and perceived safety. OVQ is used to measure the the overall organizational culture and dimensions human relation (HR), open systems (OS), rational goal (RG) and internal process (IP). It consisted of 52 items with alternative answers of the Likert type ranging from "strongly disagree" to "strongly agree". Averages were calculated for the total OVQ and for each subscale; a high score indicates strong disagreement. Minimum value 52, maximum value 520 for the total OVQ. Minimum value 13, maximum value 130 for each of the subscales. E13 measures factors such as self-estimated safety, feeling of safety, acts of violence and coercion, reaction and aggression measurements and cause of aggression in the wards. The questionnaire consists of 13 statements whose agreement is answered on a four-point Likert scale from completely agree to completely disagree. Minimum value=13, maximum value=52, higher values means better outcome. | 1 year |
| Organisations Value Questionnaire (OVQ)_Safety Questionnaire (E13) | Correlation between organizational culture and perceived safety. OVQ is used to measure the the overall organizational culture and dimensions human relation (HR), open systems (OS), rational goal (RG) and internal process (IP). It consisted of 52 items with alternative answers of the Likert type ranging from "strongly disagree" to "strongly agree". Averages were calculated for the total OVQ and for each subscale; a high score indicates strong disagreement. Minimum value 52, maximum value 520 for the total OVQ. Minimum value 13, maximum value 130 for each of the subscales. E13 measures factors such as self-estimated safety, feeling of safety, acts of violence and coercion, reaction and aggression measurements and cause of aggression in the wards. The questionnaire consists of 13 statements whose agreement is answered on a four-point Likert scale from completely agree to completely disagree. Minimum value=13, maximum value=52, higher values means better outcome. | Baseline (OVQ) and 6 months (E13) |
| Organisations Value Questionnaire (OVQ)_Safety Questionnaire (E13) | Correlation between organizational culture and perceived safety. OVQ is used to measure the the overall organizational culture and dimensions human relation (HR), open systems (OS), rational goal (RG) and internal process (IP). It consisted of 52 items with alternative answers of the Likert type ranging from "strongly disagree" to "strongly agree". Averages were calculated for the total OVQ and for each subscale; a high score indicates strong disagreement. Minimum value 52, maximum value 520 for the total OVQ. Minimum value 13, maximum value 130 for each of the subscales. E13 measures factors such as self-estimated safety, feeling of safety, acts of violence and coercion, reaction and aggression measurements and cause of aggression in the wards. The questionnaire consists of 13 statements whose agreement is answered on a four-point Likert scale from completely agree to completely disagree. Minimum value=13, maximum value=52, higher values means better outcome. | Baseline (OVQ) and 1 year (E13) |
| Organisations Value Questionnaire (OVQ)_Safety Questionnaire (E13) | Correlation between organizational culture and perceived safety. OVQ is used to measure the the overall organizational culture and dimensions human relation (HR), open systems (OS), rational goal (RG) and internal process (IP). It consisted of 52 items with alternative answers of the Likert type ranging from "strongly disagree" to "strongly agree". Averages were calculated for the total OVQ and for each subscale; a high score indicates strong disagreement. Minimum value 52, maximum value 520 for the total OVQ. Minimum value 13, maximum value 130 for each of the subscales. E13 measures factors such as self-estimated safety, feeling of safety, acts of violence and coercion, reaction and aggression measurements and cause of aggression in the wards. The questionnaire consists of 13 statements whose agreement is answered on a four-point Likert scale from completely agree to completely disagree. Minimum value=13, maximum value=52, higher values means better outcome. | Baseline (OVQ) and change in E13 (baseline to 6 months) |
| Organisations Value Questionnaire (OVQ)_Safety Questionnaire (E13) | Correlation between organizational culture and perceived safety. OVQ is used to measure the the overall organizational culture and dimensions human relation (HR), open systems (OS), rational goal (RG) and internal process (IP). It consisted of 52 items with alternative answers of the Likert type ranging from "strongly disagree" to "strongly agree". Averages were calculated for the total OVQ and for each subscale; a high score indicates strong disagreement. Minimum value 52, maximum value 520 for the total OVQ. Minimum value 13, maximum value 130 for each of the subscales. E13 measures factors such as self-estimated safety, feeling of safety, acts of violence and coercion, reaction and aggression measurements and cause of aggression in the wards. The questionnaire consists of 13 statements whose agreement is answered on a four-point Likert scale from completely agree to completely disagree. Minimum value=13, maximum value=52, higher values means better outcome. | Baseline (OVQ) and change in E13 (baseline to 1 year) |
| Number of coercive measures | Data from medical records on coercive measures, for example restraint and forced medication | From 1 year before baseline to 1 year after study end |
| Incidence of threat and violence | Deviation reports from the incidence report system "MedControl PRO" | From 1 year before baseline to 1 year after study end |