Introduction

At the heart of quality healthcare for patients is the principle that an employing organisation should ensure appropriate support and care for its staff. This can pose significant challenges for services, including those providing secure care for people with mental disorder where there is increased risk of harm occurring to staff during their daily practice. In the UK, secure mental health services provide care for patients who have enduring serious mental health problems and a history of convictions and/or challenging behaviour. The Nursing in Secure Environments scoping study (United Kingdom Central Council for Nursing, Midwifery and Health Visiting, 1999) highlighted that patients’ mental disorder and offending patterns pose intense demands on nurses because they are required to maintain empathic relationships while also focusing on risk management, including the prevention and management of violence and aggression. Further, patients may expose staff to other behaviours that are potentially distressing, for example severe self-harm and accounts of traumatic abuse.

Research suggests that educational interventions can be effective in reducing some of the effects that working with potentially violent patients has on the therapeutic relationship. Dickinson & Hurley (2012) reviewed the literature and reported that staff working in secure environments often experience strong negative emotional reactions towards patients, which can lead to antipathy and alienation. They have suggested that educational programmes should be provided to promote the building of therapeutic alliances and to increase understanding. According to Howard et al (2009), training and support for staff may increase self-efficacy and thus reduce burnout. They have called for longitudinal research to increase understanding of the relationship between violence and burnout. A number of studies have recommended that staff in secure services should be provided with effective support structures (Kirby & Pollock, 1995; Coffey & Coleman, 2001; Mason, 2002).

Despite the acknowledgment of a need for support, there has been little clear guidance about implementing any specific support model. This chapter describes the development and content of a new support model (ASSIST) for staff working in secure mental health services and the support services based on that model. We describe the contextual factors underlying the need for the ASSIST model, including the nature and prevalence of aggression and violence against healthcare staff in mental health settings and specifically in secure care.