Resima is a model for minimizing coercion, threats and violence against both patients and employees in healthcare. “After we started with Resima seven years ago, things have become significantly calmer,” says Markus Öberg, a forensic psychiatric nurse in Öjebyn.
Resima is an abbreviation of “Resources in the face of aggression”.
– But it is just as much about the preventive work. The goal is that there should be no aggression, says Christin Carlsson, nurse.
Christin Carlsson took a nursing degree with a psychiatric specialization in 1994. She has worked first in a general psychiatric ward and then for many years in forensic psychiatry.
Markus Öberg, Christin Carlsson and their colleagues Linn Hortlund, a nurse, and Jonas Lindgren, an attendant, have all completed the ten-day instructor training in Resima and in turn are training their employees in forensic psychology in Öjebyn.
Training for all new hires
There are around 180 employees: nurses, attendants, junior doctors, senior doctors, occupational therapists, counsellors, psychologists and physiotherapists.
In total, they care for 44 patients, the majority of whom are men, when all places in the wards are fully occupied.
The training held for all new employees takes three days and then they have a rehearsal for all employees twice a year to maintain continuity.
Resima is about:
- How to build good relationships between patients and staff
- How to create clear and reasonable routines
- How to calm and divert aggression
- How to prevent injury to patients and staff.
Made in Norway
The model was developed by Bjørn Petter Hanssen and Geir Olsen, who previously worked at the University Hospital in Bergen, and they are the ones who trained the instructors in, among other things, forensic psychology, but also at several other workplaces within the Norrbotten Region.
Jonas Lindgren, attendant, worked for many years in elderly and disabled care. An acquaintance suggested forensic psychology, so he applied for a job and has now been here for ten years.
The majority of the patients treated at a forensic psychiatric facility have been convicted of crimes they have committed under the influence of serious mental illness. The problem of aggression is related to the mental illness and not to the type of crime the convict has committed.
– There is a small part of our patients who explode quite quickly. In other patients, you don’t see any aggressiveness, it just flows, says Jonas Lindgren.
Abstinence
In the admissions department where they first arrive, aggressive situations are more common, which has to do with the fact that the patients have not had time to receive the right treatment and medications. Some may still be under the influence of drugs or suffering from withdrawal.
This is what a patient room might look like at a forensic psychiatric hospital in Öjebyn.
During the day, patients are offered occupational therapy when they can paint, sew, carpentry and practice cooking. Together with the physiotherapist, they can exercise or go to yoga.
If necessary, there is also the possibility of a psychological consultation. Addicts can undergo the twelve-step program.
Family atmosphere
Otherwise, there will be a lot of television watching and card games, and sometimes they cook something nice and eat together.
– It’s quite a family atmosphere, says Linn Hortlund.
Some of the patients have children and they sometimes come to visit in the special family room.
Resima includes practical exercises on how employees should act if violent situations arise. In special rooms with soft carpets, the staff practice self-defense. They also practice how to apply coercive measures, which they sometimes have to resort to, in a way that is as gentle as possible to the patient.
– As we train together according to Resima, everyone knows exactly what all the other employees do in a violent situation, says Markus Öberg.
In here on soft carpets, they train in self-defense.
Markus Öberg thinks that Resima has helped a lot to get a good working environment.
Always a way out
The preventive work is partly about such concrete things as how the rooms are furnished. For example, placing a sofa so that no one can come from behind and attack. Or how they stand or sit in the room, so that there is always a way out for both the patient and the carers if there is a tough discussion.
– As a patient, you must be able to choose to leave the room and calm down for a while if you get upset, says Linn Hortlund.
In threatening situations, you should never stand with your hands behind your back or in your pockets when talking to a patient, but be prepared to defend yourself. Also, do not stand with your arms crossed, as this may signal a threat.
As gentle as possible
Conversations that risk becoming uncomfortable, they always plan in advance.
For example, if a patient is to receive an injection against their will and it is not urgent, they decide in advance who will do what and what they will do if a situation arises where the patient opposes the injection.
On the occasions when they have to resort to force, it must be done as gently as possible.
– If I go into a situation and happen to hurt the patient, it can take several months or even longer before that patient begins to trust me again, if ever, explains Markus Öberg.
Markus Öberg came back to Piteå after working for a long time in elderly care in southern Sweden. There weren’t many jobs, so he applied to forensic psychology, where he has since worked as an attendant.
Present in the moment
In the theory part, they talk about the importance of a good “care alliance”. Being curious, interested and listening is the basis for a good relationship.
– That you are present in the moment and show that “I want to help you”, says Jonas Lindgren.
Everything is about building trust and ultimately being able to guide the patient back to a normal life in society.
– Good relationships reduce the risk of violence, says Christin Carlsson.
Easy to become home blind
It is also important to have clear and well-motivated rules.
– It’s easy to become homesick when you work here for a long time and sometimes decisions and rules remain that you don’t reflect on. It’s important to talk about them so that we don’t get stuck doing things just because we’ve always done them that way, says Markus Öberg.
Being self-aware and reflecting on yourself is also important for knowing what you radiate.
– Maybe I’m having a really bad day, have problems at home or have had a conflict with a patient that still affects me. Then it may be that I should not go in and mediate with that particular patient that day, but ask someone else, explains Markus Öberg.
Spat on
It happens that a patient verbally threatens both the employees and their relatives and becomes violent. All four have at some point experienced being punched in an upset situation or being spat on. Measures such as seclusion, when the patient is locked in, or even belting, may be necessary.
– During those situations, there is no point in trying to say so much, it is better to take it when the situation has calmed down, says Christin Carlsson.
Linn Hortlund first came to forensic psychology in Öjebyn for an internship. A year after her nursing degree, she started working here. “I enjoy myself and have fantastic colleagues.”
Being a woman and physically weaker does not necessarily have to be a disadvantage.
– Many times it can be women who go in first because they don’t perceive us as threatening, says Linn Hortlund.
Feel safe
After an incident, the employees try to get together and talk about what has happened. Both about how they feel, what they did that was good and less good and how they can avoid it happening again.
– Maybe it was something we could have done the day before or several days before. Maybe we saw that the patient was getting worse and should have done something to prevent the incident, says Christin Carlsson.
Despite everything, all four of them feel safe at work, otherwise they would not have endured in the long run.
– When I started here almost 20 years ago, there was no real model for care in coercive measures and it was bad for both staff and patients. Resima has helped a lot, says Markus Öberg.
Text and photo: Ulrika Vallgårda, freelance journalist/Yours
Facts about forensic psychology
- The patients are sentenced to forensic psychiatric care.
- The punishment is not fixed in time, but every six months the administrative court examines whether the care should continue or not.
- Some patients stay there under the Compulsory Psychiatric Care Act when general psychiatry cannot take care of them, which is usually only in the acute phase.
- In addition, they sometimes receive detained persons if they are judged to be suicidal or for other reasons in need of 24-hour psychiatric care.
- The patients have their own rooms and are allowed to move freely in their ward, where there is also a dining room and living room. Outside is a picnic area and also a park, where they can go out when the doctor deems them ready.
- Later on in the care period, they are usually granted leaves of absence which can eventually become increasingly longer.
- All leaves of absence must be approved by the administrative court following the chief medical officer’s application.
