The National Forensic Nurses Research and Development Group

The National Forensic Nurses

Research and Development Group

RESEARCH and DEVELOPMENT
NEWSLETTER

Issue 1
June 1997

Nurses working in forensic mental health care now have the support of a national group which aims to promote and establish a body of knowledge to inform practice. The National Forensic Nurses Research and Development Group was officially launched at the Forensic Psychiatric Nurses Association Conference in collaboration with the journal of Psychiatric Care and The Royal College of Nursing in October 1996.

The National Forensic Nurses Research and Development Group are now at a stage where communication of our meetings and work is essential if we are to promote R & D activity throughout the forensic community. It is with great pleasure that we send out some initial information of programmes currently being developed throughout the UK along with information regarding the current status and future group activities.

In 1991, nurses working in research in the three English special hospitals (Ashworth, Broadmoor and Rampton) and the State Hospital, Carstairs, Scotland, set up a national research and development forum. Supported by the Special Hospitals Service Authority (SHSA), the forum was a sub-group of the SHSA's professional development group. the forum aimed to:

The forum successfully launched a regular networking newsletter and facilitated two conferences on innovations in forensic services. The forum's main activities were directed to promoting research and related issues.

The SHSA ceased to exist in March 1996, but before it did members of the forum made a commitment to set up a new, independent group which would represent all branches of forensic nursing nationally.

A seminar to discuss some of the issues in shaping a new national group was convened.

A small group met in advance to agree some key principles for discussion, including:

The National Forensic Nurses Research and Development Group was officially launched at the end of October 1996. The group already has 13 members drawn from a wide range of clinical experience and research activity. There are representatives from high, medium and low security provision, psychiatric intensive care units and community settings. The group has strong links with universities and academic programmes, and three members have PhDs.

The objectives of the group are of particular relevance to nurses and other staff in generic and specialist settings who work with clients whose mental health problems result in disturbed or offending behaviour.

1. Identify contacts in all forensic and related services for purpose of two way communication:

We are currently finalising a directory of all forensic and related units in order to establish links and develop two way communications in relation to R & D activities. Link people already showing interest in networking activities will be further developed through the forensic community. We do not intend to exclude any other relevant areas such as for example, prison services, community or universities and will develop these contacts over time.

Dissemination of forensic R & D activities through collaborative networking offers some exciting opportunities for sharing ideas and initiatives and promoting research and related activities. We are currently exploring a number of ways in which to identify R & D activities and disseminate. Here we have editorial representation on the group from the journal of Psychiatric Care to encourage publication of articles. A forensic supplement to the Nursing Standard is currently under negotiation and direct links to the York Centre for Reviews and Dissemination through either a forensic database or Internet are being discussed.

The next meeting will examine how the group is moving towards its objectives and establish progress developing new priorities as appropriate. Members of the group are in the progress of task allocation to ensure each member has a clear and defined role contributing to a clear co-operate direction. We hope that this with regional links will be established early in the new year with dissemination taking place shortly after.

We hope that you will contribute towards future editions of newsletters and send details of R & D projects to share with colleagues working within similar settings. A detailed membership director of the group can be found at the end of this newsletter.

Many patients in forensic settings have histories of self-harming behaviours, sometimes resulting in serious injury or death (1,2,3). This abstract concerns the early stages of a study of patients' experiences of Self-Harm in a medium secure unit (Arnold Lodge.)

3 Use the findings as a basis for recommendations about the care of Arnold Lodge patients who Self-Harm.

The study is influenced by aspects of various methodologies, including those based on grounded theory and on feminist and related theories. These approaches are particularly concerned, both with the expression of respondents' views, and the reduction of sources of bias caused by imbalances of power between respondent and research ^(4,5,6,7)

Our research method is semi-structured interviewing, including open-ended questions to enable patients to talk about issues of importance to them. At the time of writing, nine interviews (commenced in December, 1996) have been completed.

The study commenced only after discussion with staff and patients, and local Ethics Committee approval. Ethical concerns have included consideration of whether interviews would be likely to cause patients distress (although) previous researchers have reported an absence of problems in this area ⁽⁸⁾. So far, this problem appears to have been overcome by enabling patients to make an informed decision about whether or not to take part, making it clear that interviews can be concluded at any time; and by our ongoing awareness of whether or not participants are distressed by the interviews.

Patients who take part are assured of confidentiality, except that we explain that, to ensure safety, we will inform a staff member of any expressed plans to harm self or others. In addition, there are other power imbalances between ourselves and respondents, despite our efforts to be approachable and informal. In particular, one of us (RB) works for Arnold Lodge, and is, of course, "part of the System". This is likely to affect interview responses, although it seems difficult to assess to what extent, and in what ways.

Data analysis will be concerned largely with the identification of particular themes: mainly topics mentioned by relatively large numbers of respondents. These themes may be used as a basis for further research in this area ⁽⁷⁾.

DEFINITIONS OF "SELF-HARM"

One initial finding is that, in general, patients include a very wide range of behaviours in their definitions and descriptions of "self-harm". Besides cutting and overdoses, various individuals have referred to: unwanted tattoos, taking various substances, heavy drinking and behaving in ways which resulted in others' rejection. One individual said:

We have very much appreciated the help of colleagues: and in particular, the keenness of many patients to take part, and their often thoughtful and detailed views. Further details of this research project are available from us.

Richard Byrt, Research Nurse, East Midlands Centre for Forensic Mental Health, Arnold Lodge, LEICESTER, LE5 0LE Tel: 0116 246 1262 Ext 2831

Judy Reece, Senior Lecturer, Mental Health Nursing, Dept. of Nursing and Midwifery, Scraptoft Campus, De Montfort University, LEICESTER LE7 9SU

REFERENCES

1. BURROW, S. (1992) "The Deliberate Self-harming Behaviour of Patients within a British Special Hospital." Journal of Advanced Nursing Vol.17 pp 138-148

2. HEALTH ADVISORY SERVICE (1994) Suicide Prevention. The Challenge Confronted. London: HMSO.

5. SIGSWORTH, J. (1995) "Feminist Research: Its Relevance to Nursing" Journal of Advanced Nursing Vol.22 No.5, pp 896-899

7. STRAUSS, A. and CORBIN, J. (1990) Basics of Qualitative Research., Grounded Theory Procedures and Techniques. Newbury Park: Sage.

8. POTIER, M.A. (1993) "Giving Evidence: Women's Lives in Ashworth Maximum Security Special Hospital." Feminism and Psychology Vol.3, No.3 pp 335-347

Recent years have seen an increase in the interest of the concepts of Risk Assessment and Risk Management of Dangerousness. Much information is available on the assessment of risk associated with certain behaviours (Monahan, 1988. Monahan and Steadman 1994. Pollock and Webster, 1990). Related to this, McMurran (1996) refers to the concept of "managing risk through treatment" in relation to the needs of personality disordered offenders.

However, little information is available on the practice of Risk Assessment and management of dangerousness for nurses working within Forensic Mental Health settings. The most notable exception being the Behavioural Status Index Manual used at Rampton (Reed Robinson and Woods, 1996).

It is believed within the East Midlands Centre for Forensic Mental health that before we can address and develop the specifics of Risk Assessment, we need to ensure that the basic concept of Risk Assessment of Dangerousness is developed as an integral part of practice.

In Arnold Lodge, this area of practice development is addressed through a system of Clinical Audit of the two Risk Assessment instruments currently in use. Changes in practice and training occur as a result of this.

The Comprehensive Risk Assessment is a ten category assessment of the individual and contextual factors surrounding the person's offence behaviour. Its origins are to be found in much of the recognised work on the Clinical Assessment of Dangerousness (Pollock and Webster, 1990. Monahan and Steadman, 1994) and encompass the questions outlines in the Home Office 14-item questionnaire (HMSO 1990). It is by no means a sophisticated model but, it addresses two
fundamental issues. Firstly, in its simplicity, it provides a basis for the assessment of risk as an integral part of practice. Secondly, it segregates dangerousness into its component parts, as suggested by Robinson (1996), Steadman et al (1994).

The Weekly Risk Assessment on the other hand, attempts to identify the different components from the Comprehensive Risk Assessment and uses these in defining the day-to-day management of patients. It also provides a structure by which information on the risk factors is gathered and added to the Comprehensive Risk Assessment as well as identifying areas for Risk Management through treatment. It is an eight category instrument which is completed by the named nurse in time for each Weekly Clinical Meeting. From this, decisions on high risk activities are made.

Both instruments contribute to positive decision making by encouraging a non-restrictive approach to the Risk Management of patients. This is done by identifying factors which constitute a risk in particular situations as well as identifying those factors which will minimise the opportunity for this to happen. E.g. gender considerations, times of the day and opportunities for substance abuse.

To monitor and develop the practice of Risk Assessment in each of the ward areas, Risk Assessment Co-ordinators were appointed with the responsibility of encouraging and explaining the use of the Risk Assessment models. However, overall development was co-ordinated by the author. Regular meetings were held with this group and as result, Standards on the use of the models were finalized in June 1996. The Comprehensive Risk Assessment was to be completed in time for the first Clinical Review and every three months thereafter and the Weekly Risk Assessment needed to be completed each week in time for the Ward rounds/Clinical Meeting.

The Standards were then to be used as the criteria for the Clinical Audit of Risk Assessment at Arnold Lodge.

Using the Clinical Audit Cycle as outlined by the NHS Management Executive (NHS.E 1996) as the structure, the Standards were modified on two occasions at the Risk Assessment Co-ordinator meetings, after feedback from various disciplines.

Since this time (six months), a systematic Clinical Audit of the use of the Risk Assessment instruments has been carried out at four-weekly intervals. Whilst it is accepted that the instruments are at a very basic stage, it does appear that Risk Assessment is gradually being integrated into practice. (However the Audit's focus is on quantitative data and little attention is paid to the quality of information).

The Comprehensive risk Assessment has increased from 46% (August 1996) to 70% completed overall throughout the Unit, with one ward area functioning at 100% usage.

The Weekly Risk Assessment instrument has seen its use increase from 35% to 56% over the same period.

Current plans are to develop the practice of Risk Assessment by focusing attention on the quality of the information received. This may include research surrounding the use of tools already developed in this area. (Robinson, 1996. Webster, 1995). Anyone is welcome to contact me to discuss this project or for further references.

Tony McGranaghan, Education and Quality Department, East Midlands Centre for Forensic Mental Health, Arnold Lodge, Leicester

MONAHAN, J. (1988) Risk Assessment of Violence among the Mentally Disordered: Generating useful knowledge. International Journal of Law and Psychiatry 11: 249-257

MONAHAN, J & STEADMAN, H. (1983) Crime and Mental Disorder: An epidemiological approach. In Toury M., and Morris N (Eds.) Crime & Justice: An annual review of research 145-189 Chicago: University of Chicago Press

MONAHAN, H & STEADMAN, H. (Eds.) (1994) Violence and Mental Disorder: Developments in Risk Assessment. Chicago: University of Chicago Press.

McMURRAN, M. (1996) Managing criminal risk through treatment. Psychiatric Care Vol.3 No.2. pp 51-55.

NHS Executive (1996) Promoting Clinical Effectiveness: A framework for action through the NHS Leeds: NHS Executive.,

POLLOCK, N., WEBSTER, C. (1990) The clinical assessment of dangerousness. In Bluglass, R., Bowden, P. (Eds) Principles & Practice of Forensic Psychiatry. pp 489-497 Edinburgh: Churchill Livingstone.

REED, V., ROBINSON, D. and WOODS, P. (1996) Behavioural Status Index: Named Nurse Assessment Manual for the Assessment of Dangerousness and Risk. Retford: Rampton Hospital

ROBINSON,D. (1996) Developing Risk Assessment Scales in Forensic Psychiatric Care. In Psychiatric Care Vol.3 No.4

STEADMAN, H., MONAHAN, J., APPLEBAUM, P., GRISSO, T., MULVEY, E., ROTH, L., ROBBINS,S P., KIASSEN, D. (1994) Designing a new generation of risk assessment research In. MONAHAN, J., STEADMAN, H., (Eds.) (1994) Violence and Mental Disorder: Developments ins Risk Assessment. Chicago: University of Chicago Press.

WEBSTER, C., EAVES, D. (1995) The HCR-20 Scheme: The Assessment of Dangerousness and Risk. British Columbia: Simon Fraser University and Forensic Psychiatric Commission of British Columbia.

This article describes a current research project being undertaken in the forensic setting into the assessment of risk. An assessment instrument is being developed with the intention of establishing a systematic baseline for risk behaviours which will provide individual patient data for use in treatment planning. It is anticipated that this information will assist in determining precise treatment goals and provide documentation for use in monitoring health outcomes.

The assessment under development is the Behavioural Status Index (BSI), a seventy item assessment which is being used by nurses and psychosocial day services staff within Rampton Hospital Authority. Each of the seventy items consists of a five point scale ranging from worst, to best, possible scenarios.

As Robinson et al (1996) has pointed out, there is a shortage of behaviourally based instruments with which to carry out reliable therapeutic assessments. Monahan (1988), identified the need for behavioural assessment instruments which could form the basis of treatment planning. The BSI attempts to detail patient behaviour which is indicative of risk, and which can then be used by clinical teams as the basis for decision making and related treatment interventions. As Monahan and Steadman et al (1994) report: dangerousness should be desegregated into component parts of `risk factors', `harm' and `risk level'. Monahan (1996) explains that account should be taken of the variables to predict violence, the amount and type of violence being predicted, and the likelihood that harm will occur.

The BSI consists of three sub-scales, two of which were developed by Mahgoub and Reed (1988) and the third by Dr. Robinson and named nurses from four clinical areas at Rampton Hospital Authority. The main components of the Risk sub-scale relate to a variety of aggressive behaviours, self-harm, and inappropriate sexual behaviours. The Insight sub-scale relates to items such as tension-producing thoughts, attributing dislike in others, and events producing feelings of insecurity. The Communication and Social Skills sub-scale includes items on eye contact, egocentric conversation, assertion, and relationships with others.

The terms `usually', `frequently', `occasionally', and `rarely', are used throughout in the five point scales. Because these terms are generally open to interpretation, a glossary of terminology is provided, thus enabling the assessor to identify quite precise frequencies of behaviour. The issue of frequent daily problem behaviour eventually becoming accepted by nurses as the norm for a patient, and therefore no longer recorded, was identified by a named nurse. She devised a Critical Incident Form (CIR) based on items in the Risk sub-scale which allowed nurses to record frequent problem behaviour quickly. This information could then be regularly summarised by the named nurse. This CIR was adopted for the purpose of this research project and circulated to all wards with the intention of re-focussing nursing attention on recording unacceptable behaviour. It is anticipated that this procedure will assist in using the BSI.

After two trials, the BSI is now being used by every named nurse in Rampton Hospital as part of an ongoing detailed study. In addition, there are a number of collaborating sites with which comparisons of scores can be made in medium and low secure, mainstream psychiatric and community settings. The study data collection will finish towards the end of 1997 at which time the instrument will be revised using information from statistical tests relating to the validity of each item, and from feedback from users.

Author:

Stuart Henderson, Clinical Nurse Specialist, Rampton Hospital, Retford, Notts, DN22 0PD Tel: 01777 247424

REFERENCES:

Mahgoub, N A and Reed, V (1988): `Bridging' Therapy in Hospital and Community Based Psychiatric Nursing Care: A Comparative Study (two volumes). Unpublished PhD thesis, Council for National Academic Awards (sponsoring establishment, Sheffield City Polytechnic.

Monahan, J (1988): Risk assessment of violence among the mentally disordered: generating useful knowledge. International Journal of Law and Psychiatry, 11 249-257.

Monahan, J (1996): Violence Prediction: The Past Twenty and the Next Twenty Years. Criminal Justice and Behaviour, Vol.23, No.1, pp 107-120.

Robinson, D, Reed, V and Lange A. (1996): Developing risk assessment scales in forensic psychiatric care. Psychiatric Care, Vol.3, No.4, pp 146-152.

Steadman, H.J., Monahan, J., Appelbaum, P.S., Grisso T., Mulvey, EP, Roth, L.H., Robbins, P.C. and Klassen, D. (1994): Designing a new generation of risk assessment research. In Monahan, J and Steadman, H J (eds) Violence and Mental Disorder: Developments in Risk Assessment. University of Chicago Press, Chicago.

Risk assessment particularly in deciding a patients level of dangerousness is becoming a national topical issue (Vinestock, 1996)¹. Therefore the need to develop and use accurate measures of risk assessment is essential. Patient self perception is one part of risk assessment and this abstract describes the use of a patient self-rating inventory.

The original Buss-Durkee Hostility Inventory (BDHI) (Buss and Durkee 1957)² was formerly a widely used patient self-report questionnaire on aggression. Three Dutch studies (Lange et al., 1995 a,b,c)³ developed the inventory within a detailed investigation. Here they found three factorial clusters consisting of forty items. The three factors were: Overt aggression (16 items measuring the tendency to express verbal or physical aggression); Covert aggression (19 items, dealing with repressed aggression). Additionally five items relating to Social Desirability, these indicate that respondents who tend to give socially desirable answers are less inclined to report aggressive behaviour. The Dutch experience revealed high predictive ability for the inventory.

The BDHI-D has been translated into English (Robinson et al, 1996)⁴. This version has been in use for a period of eight months. Data collection is taking place at Rampton Hospital Authority (catering for mentally disordered offenders under conditions of maximum security) and various other secure and non-secure psychiatric establishments nationally, and the normal population to establish English norm data. Patients are assessed as near to admission as possible. The inventory takes approximately 15 minutes to complete and analysis takes just a couple of minutes. Results are then fed-back to named nurses and compared with patient records to give an indication of accuracy. Data collection is progressing with a sample of 50 new admissions and data collection beginning on the resident Rampton population.

To date patients who have demonstrated high levels of both Covert and Overt aggression, but scored low on these scales after completing the inventory have tended to score highly on the Social Desirability scale - a testament so far to the reliability. Patients who have scored high on Overt Aggression and Covert Aggression tend to have low Social Desirability scores. Scoring for overt and covert aggression are analysed into very low, low, average, high and very high categories. This enables norm scores to be established for different populations. Although data is preliminary the high security forensic population shows some marked differences to all the other norm scores in respect of overt and covert aggression. Indications are a higher level of aggression in this population in comparison to others. The social desirability ranges however remain almost identical in every population. Although the forensic psychiatric population is still relatively small it has shown some interesting results. Considerable demographic data is collected which includes age and legal status. this enables comparative analysis of a number of different parameters.

In conclusion the B.D.H.I.-D. Shows promise as one element of a specific risk assessment and treatment planning strategy in psychiatric care, particularly in relation to the measurement of covert hospitality. This phenomenon is difficult to measure from an objective clinical viewpoint because of its covert nature. Measurements of this kind are usually based on `psychiatric hunches' or experience, and any instrument that can go some way towards validating such feelings must be useful. Data is accumulating constantly, and as results come in from external sites valuable analysis can be performed to give normative data which will be of use to all psychiatric practitioners.

Mick Collins, Nurse Researcher and Dr David Robinson, Senior Nurse Research and Development, Rampton Hospital, Retford, Notts, DN22 0PD. Tel. 01777 247241

1. Vinestock, M. (1996): Risk Assessment: "A Word to the Wise?" Advances in Psychiatric Treatment, Vol.2, pp 3-10.

2. Buss, A.H. and Durkee, A. (1957): An Inventory for Assessing Different Kinds of Hostility. Journal of Consulting Psychology, Vol.21, pp 165-174.

3. Lange, A, Dehghani, B., DeBeurs, E. (1995a): Validation of the Dutch Adaptation of the Buss-Dark Hostility Inventory. Behaviour Research and Therapy, Vol.33 No.2, 229-233.

Lange, A, Pahlich, A., Sarucco, M., Smits, G., Dehghani, B., and Hanewald, G. (1995b): Psychometric characteristics and validity of the Dutch adaptation of the Buss-Dark Hostility Inventory (the BDHI-D). Behaviour Research and Therapy, Vol.33, No.2, pp 223-227.

Lange, A., Hoogendoorn, M., Wiederspahn, A., and De Beurs, E. (1995c): Buss-Dark Hostility Inventory Manual; Handleiding, Verantwoodrding en Normering van de Nederlandse Buss-Dark Agressie Vragenligst (Buss-Durkee Hostility; Construction, Psychometric Properties, Validity and Norms of the Dutch Buss-Dark Hostility Inventory). Swets and Zeitlinger, Lisse.

4. Robinson, D., Reed, V and Lange, A. (1996): Developing Risk Assessment Scales in Forensic Psychiatric Care. Psychiatric Care, Vol.3 No.4 pp 146-152

CURRENT DEVELOPMENTS IN THE STATE HOSPITAL CARSTAIRS

1. The Development of a Service for Women and Minority Groups

The combination of flexible therapeutically balanced patient centred care within a setting of special security, in which women are detained, due to what is seen as `anti-social and violent behaviours' of females represented a challenging dilemma about finding an approach that would not only record and accept, but treat the violent behaviours.

In addition to the group of women who currently receive a service that is gender-neutral, there is also a small proportion of males who are either of an ethnic or disabled minority. In all, these groups presently account for approximately only 10% of the population, and invariably have not received a specific needs-led service that is sensitive to social differences.

The project aims to introduce a broader range of therapeutic strategies in the care and treatment of these women. It involves skills training and clinical supervision of all staff, which will be led by a Clinical Nurse Specialist based on the ward, and the therapeutic milieu of the unit will be monitored using the Moos Atmosphere Scale. (Moos 1974) The development of appropriate policies and protocols is also ongoing.

Funding has been sought from the N.B.S. for a study which will examine the perceptions of staff receiving supervision. This will be a comparative study as there are currently two models of the supervision process in place in the hospital. The study will explore the issues which arise from the relationship between the supervisor and the supervisee, e.g. the nature of the relationship, the establishment of ground rules, the process of supervision and the perceived benefits to each. It is hoped that the study will contribute to the development of best practice by addressing the local and particular needs of nurses, educators and managers in the Special Hospital setting.

To initiate a new approach to caring for patients with the diagnosis of personality disorder is a major task. it is not only a question of education, knowledge and skill, but a issue grounded in the attitudes and beliefs of nursing staff about the likelihood of achieving any progress with this difficult client group. The approach, Cognitive Behavioural Therapy is not difficult given the expertise of the therapist and the commitment to teaching this approach using experiential teaching/learning strategies. This is a multi-disciplinary study, using an experimental design to measure the therapeutic milieu in four wards which treat patients diagnosed as personality disordered and those with enduring mental illness. Two wards have patients undertaking C.B.T. approaches and two wards will act as a control. The study will be of 18 months duration.

1. "The Relationship between a Medium Secure Environment and Occupational Stress in Forensic Psychiatric Nurses"

By using a package of approved empirical psychological assessment tools plus a home made demographic questionnaire all the ward based nursing staff within the Hutton Unit were surveyed to determine their perceptions of their levels of Occupational Stress and how that correlates with their perceptions of their ward atmosphere. The investigators' hypothesis was disproved due to the very favourable results.

Completed - Was published in the November 1995 issue of the Journal of Advanced Nursing and has been presented at numerous local. National and international conferences.

By using a package of approved empirical psychological assessment tools (Ward Atmosphere Scale) of the patient and nursing groups of the medium secure long stay ward. Similar responses were taken from patients and staff of the service pre-discharge ward for comparison, both patient groups being deemed to be `long stay'. Both ward areas are based within the Hutton Centre. These groups were surveyed to determine their perceptions of their levels of their current wards and gain a baseline picture of the therapeutic nature of the long stay ward. The investigators' hypothesis was disproved due to the very favourable results.

Current Status:

Study completed, presentation made to Forensic Service staff and manuscript has been submitted for publication

3. "A Comparative Study of Admission Rates between two Regional Secure Units.

Taking the admission figures from both the Hutton Unit and the Norvic Clinic in Norwich and subjecting them to various variables, such as diagnosis; section of the M.H.A.; length of stay; criminal record (if any). Then doing a straight forward comparison of the figures.

All data has been collected and processed and is currently awaiting to put into document form.

4. "Malingering and Feigned Illness within Forensic Psychiatric Patients and the nursing approach to such patients."

Looking at the statistical figures of patients who are currently inpatients of the Hutton Unit and those who have been referred and, by using an empirical psychological tool, determining those who are feigning or exaggerating mental illness. From this then to move on to look at possible nursing interventions of such people.

Completed - Has been accepted for publication by the Journal of Psychiatric and Mental Health Nursing.

5. "Development of a Multi-Disciplinary Risk Assessment Tool"

This project is intending to look at developing a tool which will/can be used in the assessment of risk through all areas of the patients stay within the Forensic Service. This obviously has wider usage in the field of Adult Mental Health as a whole.

A grant from the R & D Committee has been awarded to fund an associate investigator. To commence shortly.

To canvas the opinions of patients; staff; relatives/visitors and service purchasers of the Forensic Service to determine their satisfaction levels of the service we deliver.

Questionnaires have been distributed; returned but due to the poor response rate the project was not viable - is currently being examined to implement it again in the near future.

By taking statistical figures from in-house: the Home Office and other sources to determine if there has been an increase in these transfers or not.

By taking an existing study and expanding upon it and providing more empirical validation it is hoped to develop an assessment tool for use in profiling and assessing paedophilic offenders.

Initial work of acquiring and developing assessment tools is almost complete, a pool of subjects has been drawn up. Interview work hoping to commence shortly. Elements of this project will form the dissertation phase of one of the investigators' M.Sc. Course.

9. "Looking at the Functions; Role Within and Climate of the Multi-Disciplinary Team within the Regional Secure Unit"

By utilising an existing empirical psychological tool and canvasing the opinions of ALL members of the Multi-Disciplinary Team (i.e. everybody who works on the Hutton Unit) it is hope to determine peoples impressions of their roles within the M.D.T. and how they differ from other people's roles and impressions of team functioning. The tool offers suggestions for rectifying a dysfunctional team. It is intended that this will follow on from the Occupational Stress study and support (or not) those findings.

10. "Patient Satisfaction within a Medium Secure Long Stay Ward (provisional)"

To follow up the Ward Atmosphere Study of patients within a medium secure Long-Stay ward this study aims to elicit their degrees of satisfaction of their current environment.

Project is still in the planning stage; tool being formulated and ethical approval being sought.

A descriptive study of the `Prison Health Care Contract' was carried out, looking at the numbers and types of referrals made to the Prison Health Care staff. This has implications on the future service that is provided to the `Durham Prison Cluster' by highlighting trends in types of referrals and the amount of input that is required by the different disciplines involved within this contract.

Study completed, report completed and is currently being `proof read' prior to submission to Prison Headquarters before submission for publication.

There are numerous small discussion and descriptive papers being written and put forward for publication.

This research examines approaches that may contribute to the identification and quantification of physical and/or sexual abuse suffered by in-patient population of Regional Secure Units. This study specifically examines possible links between physical/sexual abuse suffered by an in-patient population of mentally disordered offenders in childhood or adolescence and the prevalence of violent or aggressive offending in this group in later life.

The study interest is in, what may be termed as a cycle of abuse theory of violent offending which stems from experiences of working as a staff nurse, charge nurse, and clinical nurse advisor in a Birmingham Regional Secure Unit, Reaside Clinic. Here, regular evidence of abuse, both sexual and physical in the childhood and adolescent careers of violent offenders referred to the medium secure unit is noted. As a consequence of work in this area at the clinic I was drawn to further examination of how to define the physical/sexual abuse suffered by the in-patient group, as well as quantification of this abuse. In previous examinations it was clear that the quantification or measurement of severity of physical/sexual abuse suffered by violent offenders was compounded by definitional problems. This observation is complemented by Hamilton (1987), who has indicated that:

In examining specific mental disorders suffered by the physically/sexually abused in patient population of violent offenders a ranking and classification system was designed related to the severity of abuse suffered. As a consequence, I am in a position to examine links between the two. Further examination involved the validity of using an overall mean score obtained from three decision makers, examining the severity of physical sexual abuse suffered by the group. Findings from score values obtained from three decision makers (health professionals) and their scores, made subject to correlation determinations, have resulted in the validation of the use of an overall mean score to measure severity of abuse suffered by each patient.

An extension of this previously completed work (November 1995) to other forensic areas, (Medium Secure Services) has occurred. Contacts have been established in other secure units extending both the sample size and consequently this study. The value in examining whether the samples are representative of forensic services overall is clear. In studies undertaken by Spatz Widom (1989), in the area of intergenerational transmission of violence she has concluded that case histories of small samples have minimal statistical usefulness, and the extension of work in this area to the services indicated would appear to be an opportunity to overcome this problem. The work completed to date cannot be said to be representative of mentally disordered offenders in England, or of a violent group of offender in-patients in England, therefore the extension of this work to all of the medium secure units in the UK will be of clear value in examining a cycle of violence in violent offenders who have been physically or sexually abused during childhood and adolescence. The value of further examining multidisciplinary decision making with respect to quantifying such abuse is also clear. Both Browne (1988) and Browne and Herbert (1995) point to the usefulness and importance of work in this area.

The research proposal will involve two studies; the first study will detail the prevalence of sexual/physical abuse suffered in childhood and/or adolescence by violent offenders within the chosen regional secure units further examining characteristics of this group such as ethnicity, diagnosis and gender. The second study will examine the severity and quantification of the abuse suffered, examining in detail the definitional problems associated with abuse, physical and sexual, suffered by this client group.

The second area of the work then will be a ratification of what constitutes abuse in this group, and there will be a subsequent attempt to quantify the abuse suffered, by examining score values obtained from health professionals. This will be undertaken subject to correlation determinations, in turn examining the validity of mean scores in this area.

The proposed research involves ethical approval from various regional secure units or relevant health authorities, and a prolonged period of data collection and case analysis. This process would be followed by an assessment of findings following evaluation of data.

There is potential in that such work could significantly influence the design of interventions for those who are abused in childhood or adolescence, and in turn possibly have an effect on service provision. The implications for training and educational provision in youth treatment centres, and amongst clinicians working in forensic practice could also be influenced by such research.

Mr. Norman McClelland, Lecturer in Forensic Psychiatric Nursing, University of Birmingham / Reaside Clinic

REFERENCES

1. Browne, K., Davies, C. and Stratton P. (1988) Early Prediction & Prevention of Child Abuse Chichester: John Wiley & Sons

2. Hamilton, John R. (1987) Violence and its Victims. The Contribution of Victimology to Forensic Psychiatry. The Lancet January 17 Pages 147-150

3. Widom, Cathy Spatz (1989) Does Violence beget Violence? A critical examination of the literature Psychological Bulletin Vol. 106 No.1 Pages 3-28

4. Widom, Cathy Spatz (1989) The Cycle of Violence Science 244 Pages 160-166 April