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International Journal of Forensic Mental Health 2005, Vol. 4, No. 1, pages 39-52

The Security Needs Assessment Profile: A Multidimensional Approach to Measuring Security Needs Michael Collins and Steffan Davies Although levels of security in UK forensic psychiatric services are generally accepted as being divided into high, medium and low security there are few detailed descriptors beyond those of high security. The lack of clear definitions of security poses problems for researchers, clinicians and patients. Developments in forensic care increasingly demand that patients should receive care under conditions of security that are no greater than necessary to manage the risks they present. This is not a simple proposition; a number of complex areas have to be addressed by clinicians when defining a patient’s individual needs for security. In an attempt to provide a more comprehensive description of patients’ security needs the authors developed the Security Needs Assessment Profile (S.N.A.P). This instrument builds on the three traditional dimensions of security: physical, procedural and relational. Each dimension is sub-divided into a number of items, 22 overall. Each item was described on a four-point scale, each point being carefully defined to provide reference points for users. This article briefly outlines the background, instrument development, instrument structure, sample and results. Initial results indicate that the instrument can distinguish between patients who require different levels of security. An emerging component structure is also described. A preliminary version of the instrument is described for use in forensic settings. Forensic psychiatric patients are treated under differing levels of security, yet definitions of security are often simplistic and do not reflect the complexity of differing needs associated with different risk behaviors. Secure services in the UK are traditionally categorized as high, medium and low yet there are no widely accepted definitions outside of high security making such distinctions, at times, difficult to quantify. Kennedy (2002) describes “a wide variation between services, e.g. in the level of physical security in medium secure units” (p. 433). This is changing in some areas; the security provided by the UK High Secure Hospitals has been standardized following a recent review of security (Tilt Report, 2000). There has been some critical debate regarding the focus of this report on physical and procedural security (e.g., Exworthy & Gunn, 2003). Low security environments may become more standardized by complying with recent guidelines for “National Minimum Standards for General Adult Services in Psychiatric Intensive Care Units (PICU) and Low Secure Environments” (Department of

Health 2002). Our clinical experience suggests wide variation between services. One example is varying fence height across services that provide medium security despite the design guidance issued by NHS Estates (Department of Health, 1993). These guidelines included recommendations for perimeter fence height, structure, and a range of environmental features. Other security elements (e.g., staffing levels) and procedural and relational measures may enable a service to provide ‘medium’ security without over reliance on a perimeter fence of a particular height being the most important factor in the designation of security level. In some countries, the United States being one, fence height may have little to do with security designation; in the UK, it tends to reflect the degree of internal restriction faced by patients. The lack of any widely accepted definitions of security provision or ability to measure security in any fine-grained, reliable way is a barrier to the clinical desire to provide a more needs led service.

Michael Collins, Rampton Hospital, Nottinghamshire Healthcare NHS Trust, United Kingdom; Steffan Davies, Rampton Hospital, Nottinghamshire Healthcare NHS Trust & University of Nottingham, United Kingdom. We would like to thank Joel Dvoskin for his valuable comments and assistance with this article. Correspondence concerning this article should be addressed to: Michael Collins, R & D Department, Rampton Hospital, Nottinghamshire Healthcare NHS Trust, Woodbeck, Retford, Notts, UK, DN22 0PD (Email: [email protected]). ©2005 International Association of Forensic Mental Health Services

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In the UK, there is a history of patients being detained under conditions of security greater than is necessary, in particular in high security. A number of studies have highlighted these problems (Bartlett, Cohen, Backhouse, Highet, & Eastman, 1996; Maden, Curle, Meux, Burrow, & Gunn, 1993; Murray, Rudge, Lack, & Dolan, 1994; Pierzchniak et al., 1999; Shaw et al., 1994; Taylor, Butwell, Dacey, & Kaye, 1991). A feature of such studies is varying estimates of the numbers of patients who are inappropriately detained. This may be due to differing methodologies, regional variations and changes in patient characteristics over time. Certainly recent years have seen reductions in patient numbers detained in high security as a response to such studies and government policy. Abbot (2002) describes how reductions in the number of patients in the high-security hospitals over the last 10 years is a result of “creaming off” whereby the least complex cases are discharged first. The implication is that the high security hospitals will be left with smaller numbers of more complex and higher risk patients. Sayal and Maden (2002) describe how previous estimates of levels of inappropriate detention may now be outdated, and question discrepancies between views of the team treating the patient within high security and the team who would care for them in a lower secure setting. Such discrepancies can exist for many reasons, and the authors hope that the use of the instrument described in this paper may help resolve such differences. UK National policy has striven towards the detention of patients under conditions of security commensurate with the risk that they present. This was emphasized in the Reed Report (1994), the NHS National Service Framework (NSF) for Mental Health (Department of Health, 1999) and the Tilt Report (2000). More recently Part II of the White Paper Reforming the Mental Health Act 1983 (Department of Health and Home Office, 2000) states: ‘Where individuals are detained as a result of their mental disorder, they must be held in a therapeutic environment which is designed to address their needs effectively. This is not just a matter of new places, important though that is, but also properly trained staff, new approaches to assessment and treatment, and a rigorous program of research and evaluation’ (paragraph 6.23). The Mental Health (Care and Treatment) (Scotland) Act (2003) goes further and gives patients a right to appeal to be

transferred to conditions of lower security. There is evidence of an emerging rigorous research program, but we argue that more studies must focus on the fine-grained definition and measurement of security need in terms of new approaches to assessment. Defining Security In the UK, members of direct care staff usually provide and administer security, as well as manage individualized modes of treatment (although members of qualified nursing staff are usually responsible for more complex security decisions). The complexity of this task, particularly in regards to high security levels, is easily underestimated. Parker (1985) identified four factors of security: physical security, quality of nursing care, the control of patients, and patient motivation. The 1990s saw some of the first extended policy definitions of security from Kinsley (1992) who described how a combination of good basic physical security and related systems should provide the opportunity for a relatively relaxed regime within these boundaries. Furthermore, efficient security measures should improve treatment and provide a safe environment within which patients can progress. This reference to related systems can be considered as dynamic elements and these are described further under the headings of procedural and relational security that follow. Later literature expanded these concepts describing security and therapy as not mutually exclusive but complimentary factors (Kinsley, 1998). These developments should be considered in light of not only the growing body of evidence that there were a large number of patients detained in inappropriately high levels of security, but also in the context of an attempt to challenge the sometimes misplaced image of security being provided without reference to any therapeutic factors. Security is currently considered as having a theoretical separation into three domains: Physical. The most obvious aspect of security is the physical elements. These can include: perimeter fences of particular height and style of construction, electronic intrusion alarms, locks (including electronic locking mechanisms), doors and CCTV cameras. Procedural. This domain covers the variety of procedures that take place within the physical

Security Needs Assessment

elements to maintain security integrity. Examples include the restriction of certain items within a unit, the searching of patients and the environment, frequency of patient observation, staff to patient ratio and supervision/restriction of visitors. Relational. This domain is more complex, but in general refers to a detailed understanding of those receiving secure care and how to manage them. For example, a competent forensic nurse will have an extensive knowledge of a patient. This will include potential risk behaviors and a relationship with the patient that includes an open acknowledgement of the potential for dangerous behavior. This level of knowledge allows the practitioner to constantly assess behaviors, patterns of behavior and changes in mental state that have a direct relationship to any immediate or potentially dangerous behavior or similarity to offending patterns. This level of knowledge can enable care to be delivered in an environment where levels of restriction and supervision can be varied according to the needs of the patient while maintaining the protection of others. The combination of these three domains is sometimes termed as therapeutic security, whereby therapeutic interventions take place within the domains and that these are tailored as far as is practical to the individual patient need. Therefore, while any separation may be regarded as artificial because good secure care will involve a combination of all three domains, it is useful to make theoretical distinctions to aid assessment. The Measurement of Security Need Traditional concepts of security either make the error of restricting themselves to descriptions of physical elements, such as perimeter fences, doors and locks, or use ill defined terms such as low, medium and high, making the assumption that these are descriptive enough in their own right. Over a decade ago the Reed Report (1994) called for “a patient focused definition of what high security connotes” (p. 21); a recommendation that is equally relevant to other levels of security. The measurement or assessment of security need is complex. Maden et al. (1993) described the ill definition of the boundary between medium and maximum security and how the security needs of most patients had more of a relationship with nursing

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care and the internal hospital environment, as opposed to the perimeter fence. If we ask the question ‘what do we mean when we say a patient requires high security?’, once we get past basic considerations like the height of the fence and other physical elements, other factors become far more difficult to quantify. These other factors are numerous; Taylor, Maden, and Jones (1996) outline some further aspects to be considered when assessing security need including physical and detailed staffing issues as well as perimeter and internal hospital security. They reasoned that distinctions between high security and purpose designed medium secure units were diminishing. While this may have been the case, a recent review of high secure services in the UK has created more standardization and heightened physical and procedural security measures (Tilt Report, 2000). The ability to measure subtle differences, particularly within procedural and relational security, offer greater possibility for discrimination between regimes in high and medium security. Security is, of course, only one aspect of a patient’s needs within secure services (e.g., Exworthy, 2000); however, given the considerable expenditure devoted to patients in secure services and a desire to get levels of security right for patients in these services, attention to the measurement of security need is of paramount importance and developments have lagged behind other areas of needs and risk assessment. There have been more recent endeavors to develop measures that address security needs. Coid and Kahtan (2000) developed an instrument to predict the security needs of patients in medium security. They describe the need for accurate definitions of security need and a lack of agreement on definitions and methods currently available to allocate patients to the correct levels of security. Their four point rating scale is designed for use within medium security and describes patient characteristics that are related to security need in terms of low, medium and high security. They concluded that ‘there is no single criterion that can determine the security needs of an individual patient’ (p. 125). Shaw, Davies, and Morley (2001) developed a measure of the security, dependency and treatment needs of patients (SDTP). The measurement of security needs concentrated upon risk of violence and absconding and utilized a visual analogue scale

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for Responsible Medical Officers to rate need. While such a scalar measurement method provides greater scope for differentiation amongst patients, the authors acknowledge that the scale has ‘no external reference points’ (p. 626). One of the findings of this study was that differentiation of patients was more accurate using dependency needs than security needs. In a review of recent academic literature Williams, Badger, Nursten, and Woodward (1999) described how “few of the studies define ‘high’ or ‘medium’ security, or differentiate between and observational security measures” (p. 307). Sayal and Maden (2002) outlined the need for the development of standardized scales to measure security needs and also called for further research into the interrelationships between risk, level of functioning, and environmental conditions and their relevance to the appropriate placement of patients. Beck-Sander and Kinsella (1998) describe the need for developing standardized criteria to measure patient suitability for admission, internal transfer and progress within the unit. Measurement of security need is underdeveloped in relation to measures of dependency, risk, and more global needs assessment. This may be a conceptual issue and there is some inevitable overlap between certain areas of dependency and security. For example, nursing supervision is traditionally regarded as a measure of dependency and in many contexts this may be the case (e.g., assisting with personal care). However, if supervision is provided as part of a forensic risk management care package, then we must consider that within this context it is more accurately categorized as a security need. Within most UK forensic settings it is members of direct care staff that administer security. The staffing ratio in a unit is often regarded as a highly important security measure; however, the training and ability of the staff in terms of security are also important. There is a developing forensic nursing literature that describes the importance of relational security (e.g., Burrow, 1994; Collins, 1999; Woods, Collins & Kettles, 2002) as part of forensic psychiatric care. Despite recent work on assessing security needs, there remains a need for an instrument that comprehensively describes the elements of security provided within forensic psychiatric services. Such an instrument needs to be multi-dimensional to capture the many different components of security

provided in modern forensic services and needs to have clear definitions of its items to encourage greater consistency in patient assessment, definition of services and for research purposes. Instrument Development The Security Needs Assessment Profile (S.N.A.P.) attempts to measure security need across open, low, medium and high secure forensic mental health services. The end result of an assessment is a security needs profile that is able to match a patient to a service. The individual items were initially derived from the perspective of High Security, as patients are more likely to exhibit the most extensive range of security needs We arrived at 22 criteria after extensive consultation with multidisciplinary colleagues which, importantly, included consultation with specialist security liaison nurses. (These are mental health nurses with specialist training in security attached to clinical teams to provide expert advice on security issues related to individual patient need and treatment). Each of the 22 criteria was categorized into physical, procedural or relational security. Following further consultation with colleagues in medium, low, and open forensic services, the criteria were carefully defined and an ordinal scale of zero to three developed. Zero represented the absence of security need and three represented the highest level. Broadly this corresponds to traditional definitions of open, low, medium and high security but is not intended to be prescriptive due to high levels of variance amongst some units that offer the same ostensible level of security. Each ordinal item was criterion referenced. Criterion referencing involves attaching a descriptor to each ordinal scalar item. This improves interrater reliability and has advantages over Likert- type scales which tend not to define scalar items in any great detail. This approach to measurement in forensic psychiatry has an established and successful pedigree (e.g., The Behavioural Status Index; Reed, Woods, & Robinson, 2000). Such definition is important in the light of other study findings; for example, Burrow (1993) found differences between ratings of security need between psychiatrists and nurses. Similarly the differences between accepting and referring teams outlined by Sayal and Maden (2002) highlight the need for a

Security Needs Assessment

more reliable, comprehensive, and structured method of security needs assessment. The draft instrument was again reviewed by multi-disciplinary colleagues and further refined. Initial guided piloting resulted in further amendments.

SECURITY NEEDS ASSESSMENT PROFILE CRITERIA Domain 1. Physical Security Items 1. Perimeter. A perimeter of some type represents one of the primary physical security measures. Perimeter fences or walls vary in height and type. They may be of a single or double perimeter type and be constructed from climb proof mesh. Electronic detection systems, closed circuit television and security lighting also play an important role. 2. Internal. A good perimeter is not necessarily a deterrent to the most agile and determined absconder, nor does it provide internal structural protection for others. Internal building quality and general layout vary according to security level and need. Examples include the resilience of doors, ceilings, locking mechanisms and windows to prevent attack from individuals and the provision of alarms and internal closed circuit television. 3. Entry. Any security system needs to have a point (or points) of control over what comes in and out of the secure area. Generally the higher the risk containment required the higher would be the level of control needed. The highest levels of security will have a very limited number of entry or exit points with facilities to scrutinize both people and goods. 4. Facilities. When patients have to leave the secure perimeter, the level of risk is raised. For example, risk of the opportunity to abscond increases. If all routine recreational and treatment facilities are housed within the secure perimeter, risks and inconveniences to patients are minimized. Such a high level of provision is a particular feature of high secure services in the UK where most recreational and limited general medical facilities are provided within the secure perimeter, negating the need for patients to leave the perimeter for any routine or common reasons. It is likely, however, that special circumstances will remain in which it will be necessary for patients to leave the perimeter (court

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attendance for example, although in some hospitals in the United States, courtrooms are provided). Domain 2 Procedural Security Items 5. Nursing Intensity. This is a collective term for the level and frequency of direct patient supervision. Such supervision is related to risk management, maintenance of security integrity and safety. The details of patient whereabouts and activity will be noted at specified time intervals. The ability of a service to respond with heightened observations/ supervision/incident support without compromising the level of care offered to other patients is also a key aspect of this item. 6. Patient Characteristics. Careful consideration needs to be given to placing patients in particular environments. Areas for consideration include diagnoses, gender, and offence profile. An example would be ensuring that patients with a predatory nature are not mixed with those who are vulnerable. 7. Searching. It is necessary to search individuals for prohibited items. At higher levels of security, patients, their belongings and living areas are subject to routine and random searches, including when patients move to and from different areas within and outside the perimeter. The frequency of such searches will depend on the type and severity of the risk being managed. This includes ‘pat-down searches’ of patients, room searches and also non-intrusive measures using metal detector portals and X – Ray machines. 8. Access to potential weapons and fire setting materials (including items that may be used to breach security). Weapons are often conceptualized in the form of knives and guns or other obvious items. While patients may need access to such daily items as knives and forks, these can be managed by regular checks. It is, however, easy to fashion a weapon or device to breach security from everyday items. For example, adhesive tape can make a very effective garrote or a coat hanger can become an effective device for scaling a fence. Differing levels of control and procedures limit access to such items and help ensure the safety of patients and staff. 9. Internal movement. At the highest level of security, internal movement of patients is subject to high levels of supervision, which may involve centralized control and permission being sought for

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all movements. There may need to be a general awareness of all patient locations at regular intervals; all movement must be carried out under varying degrees of supervision. However, even within high secure facilities, provision exists for the introduction of more relaxed regimes such as internal ground parole. 10. Leave. When patients leave the secure area they are subject to a varying degree of restriction. High security has the provision for special secure vehicles which are self contained, including toilet facilities and radio communications. Conversely, systems exist for increasing freedom and moving eventually towards unsupervised leave. 11. External Communications. It may be necessary to place restrictions upon or to monitor external communications. This may be for the protection of others (for example previous victims), the patient (e.g., manipulation by others), or to prevent collusion/illicit activities (e.g., planned escapes). Methods of external communication vary widely, the most common being the postal and telecommunications systems. 12. Visitors. Visitors represent a vital and therapeutic part of hospitalization but can present a weak link within a security system. Visitors will be subject to varying levels of scrutiny and supervision (they may be at risk from patients, or present a risk to patients) as will any items that they bring in for the patient. 13. Visiting children. Children may be at risk when visiting a secure establishment. This may not only be from the individual being visited but also from other detained individuals, who could for example have a history of offences against children. In appropriate situations, such visits may have vital therapeutic value, but may need to be catered for in special visiting areas, under the supervision of staff trained in child protection. 14. Media exposure. Certain patients generate intense media interest. This needs to be monitored and in some instances managed. Some units have developed sophisticated techniques for handling media interest, including dedicated media relations staff and external PR consultants. 15. Access to illicit substances. A number of patients within forensic services often have some history of substance misuse. Access to illicit substances may lead to deterioration in mental state.

Trading in illicit substances can lead to problems with discipline, bullying, extortion and repeated attempts to undermine security. Varying systems exist (over and above general searching) to detect such substances. For example, the use of random drug testing procedures. 16. Access to alcohol. This is similar to the category above, but is included as a separate item because supervised access may be permitted in lower security. Special awareness may also be required for illegal homemade alcohol. 17. Access to pornographic materials. Public availability of pornography has widened in recent years not only in published form, but also via video and other audiovisual mediums (the Internet is considered as a separate category). Certain offenders may obtain sexual stimulation from seemingly innocuous sources and this phenomenon should be considered as part of any risk management strategy. Generally, this is an issue of monitoring access and patients at any level of security may be able to have access to pornography that is legally obtainable. There may however be circumstances within certain treatment plans that restrict the possession of pornography. 18. Access to information technology. Information technology has created a whole new range of security issues. The availability of pornography or sensitive information on the internet can create a range of security issues as can the possibility of collusion between individuals. Varying levels of restriction exist to control such risks, ranging from no access to limited access under supervision or the use of dedicated restriction software. Domain 3 Relational Skills Items 19. Management of violence and aggression (MVA). These skills fall into two main areas. First and foremost are the skills of recognizing and dealing with situations before they escalate to physical aggression. Second are the physical skills from basic breakaway techniques to physical intervention. Highlevel skills include the use of protective equipment and hostage negotiation skills. In all units where MVA skills are regularly used, training should be regularly updated and where possible regular supervision provided by staff who provide the specialist training.

Security Needs Assessment

20. Relational nursing skills. Close knowledge of individual patients and how offending behavior is mirrored within a secure environment is vital to treatment, progress, and risk management. For example, a patient’s ability to conspire and manipulate can present enormous safety and security problems if unchecked, while the identification and management of such behaviors can be valuable contributors to treatment. Nursing knowledge and observation contribute to formal risk assessment, risk management and treatment planning and can identify risk behaviors before they reach crisis point. 21. Response to nursing interventions and treatment program. The response of patients to nursing interventions and all other treatment components is an important relational security consideration. Non-response and active avoidance of treatment or even attempts to subvert procedures usually have implications for heightened security measures. Specific skills are required to engage patients in treatment. 22. Security intelligence and police liaison. Patients in forensic care are often offenders. Although unusual, some patients have extensive networks of criminal contacts. Security considerations include attempts to escape, attempts to bring in weapons or other illicit items, and intimidation of staff and patients. Active security intelligence systems may prevent security breaches and contribute to risk assessment, management and treatment. Higher levels of security will generally have dedicated security liaison staff and systems for recording and

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building security intelligence. At higher levels of security, there may also be a greater need for police liaison and other elements of law enforcement. An example of detailed ordinal descriptors is provided for item 19 in text box 1. The decision on the different ordinal levels was taken on an examination of current forensic services, mainly within Trent region in the UK but drawing on experience of other services. While level 3 generally represents high security, the provision of security varies more widely in units classified as low or medium secure. Should a subject demonstrate a high level of need on some of the criteria, then the only placement suitable would be a high security hospital. This indicates that within the instrument there will be some items that represent “drop dead” issues. For example, if a patient presented a high and immediate risk to others if at liberty and a risk of escape that necessitated a high level of perimeter security then the patient would be detained in high security, irrespective of scores on other items. This would not prevent a more tailored care package within the perimeter. Other items are quite obviously cumulative in nature, so that a person with 10 points over a range of items is likely to need lower security than a person with 20 points. This is why the instrument is an aid to clinical decision-making, and while scoring properties are useful, practitioners should not lose sight of examining each criterion on its individual and cumulative merit. We intend to examine these issues in extended clinical studies.

Text Box 1 Example of Ordinal Descriptors for Item 19, When Considering the Needs of the Patient in Terms of Management of Violence and Aggression (MVA). 3: All direct care staff fully trained in MVA techniques. Some staff will have extended training in the use of protective equipment and hostage negotiation skills. There will be recourse to large numbers of trained staff backup in emergency situations for extended periods. 2: All direct care staff trained in basic breakaway techniques, at least 80% of staff with full basic MVA training. There will be limited recourse to staff backup in emergency situations for limited time periods. 1: All direct care staff trained in basic breakaway techniques, selected staff members with full basic MVA training. 0: All direct care staff are required to know basic non-physical intervention skills and breakaway techniques. (N.B. MVA training includes recognition of warning signs, verbal de-escalation and avoiding physical confrontation etc.)

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The instrument was initially piloted and utilized at Rampton High Security Hospital in the UK (as part of a wider study assessing patient needs, approved by Rampton Hospital Ethics committee). It was also used for an audit of Trent Region patients’ security and treatment needs and submitted in a report (Davies, Collins, Hogue, Barrs, & Eitel– Smith, 2001). Two of the primary aims were to compare the S.N.A.P. scores to clinician overall ratings of security need and make a preliminary examination of the instrument properties.

RESULTS We obtained S.N.A.P. data on 147 subjects. These were male patients with a mental disorder (excluding those with learning disability) detained in secure services across the UK. Data were obtained from either the patient’s psychiatrist (termed the Responsible Medical Officer (RMO), or primary nurse. For 110 of the subjects we were able to obtain a rating from both the RMO and primary nurse. Table 1 outlines the levels of security from which the sample were drawn. While decision-making regarding placement needs to be informed individually by the 22 items, the authors envisaged that scoring patterns would provide useful information about the sample. The RMO/Primary nurse were also asked to state what they thought would be the best placement for the patient e.g. long-term, severe mental illness service and level of security rated as: 0 – Open, 1 – Low Security, 2 – Medium Security, 3 – High Security. While none of the patients in the sample were in open settings it was still important to include an open setting as an option as patients may be appropriate for such settings. We have to point out an inherent weakness in our methodology at this point, in that

asking both the RMO/primary nurse to provide both the S.N.A.P. and best placement rating is a potential methodological weakness. “Blind” ratings, where the best placement rater did not know the S.N.A.P. ratings would have been preferable. This would have been possible through the use of external rating teams or trained observers. We did however feel that a comprehensive S.N.A.P. and best placement rating requires an in-depth knowledge of the patient’s security needs that is difficult to achieve using external assessors. The best placement rating was felt to be a superior comparator for S.N.A.P. scores over the current placement as it removed any inherent bias of patients detained at an inappropriate level of security. Despite some inherent covariance the data gathered still provides useful preliminary data about the S.N.A.P. Table 2 shows mean patient scores in the physical, procedural and relational domains of the instrument compared to the clinician best placement ratings. The table demonstrates that high best placement ratings are associated with greater domain scores. These have to be treated with some caution as the standard deviations (SD) are high, particularly for procedural security. The SD indicates to what extent individual scores are dispersed around the mean. This can be accounted for by the larger number of items within the procedural security domain and the fact that individual patient needs in this area will be variable, even when they have the same best placement rating. For example, two patients may both have medium needs for searching and access to weapons but very different needs for access to pornography and information technology. The final column shows the cumulative effect, but it is interesting to note that those patients with a best placement rating of high security have the lowest SD despite having the highest instrument score. For this part of the analysis we used the RMO S.N.A.P.

Table 1 Security Level Placement of Subjects at Time of Assessment Security Level Low Medium High Total

Number 20 68 59 147

Percent 13.6 46.3 40.1 100.0

Security Needs Assessment

score and best placement ratings in preference to the primary nurse ratings. The split was 129 RMO ratings and 18 primary nurse ratings (we had 18 missing RMO ratings). This is because out of the two clinicians the RMO is the one ultimately responsible for recommendations in patient security placement. We were interested to know if there was any statistically significant difference between the mean overall scores for the open, low, medium and high best placement groups. These were 15.11, 26.19, 32.39 and 49.75 respectively. A one-way analysis of variance (ANOVA) test revealed a significant difference, F (3, 143) = 46.37, p < 0.01. This result indicates a difference between the means but, as there are four groups (open, low, medium and high security best placement ratings), we conducted a Tukey honestly significant difference comparison to reveal where the statistically significant results occurred. We found that when comparing medium and low security they were not significantly different. The mean difference in overall score was 6.2, p > .05. All other possible comparisons showed significant differences (high/medium, 17.6, p < .01; high/low,

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23.6, p < .01; high/open, 34.6, p < .01; medium/open, 17.3, p < .01; low/open, 11.1, p < .01). This is further illustrated in Figure 1, a box and whisker plot, an alternative way of presenting the data. This is based on medians (the value that is halfway through the ordered data set above and below which there are an equal number of values). In figure 1 the bold horizontal line in each of the four shaded boxes indicates the median for each of the four best placement groups. The lower portion of the shaded boxes represents the 25th percentile and the upper portion the 75th percentile. The vertical lines or whiskers represent values out of this range (outliers). It is also noticeable that outliers contribute to score variation. We deliberately left outliers in the data set, as in this study they are not necessarily representative of ‘flawed data’. This is an indication of the complexity of the subject area where a patients need profile is lower or higher than the main groupings. We referred earlier to “drop dead” items and this again suggests that there will always be a need to consider the results of any instrument, in the light of supporting clinical judgment and public safety considerations.

Table 2 Mean Security Scores Compared to Clinician Best Placement Rating

Best Placement Rating

Physical Security Total

Procedural Security Total

Skills Total

Combined Physical, Procedural and Skills Total

Mean N SD

2.57 28 2.834

9.04 28 8.804

3.50 28 2.301

15.11 28 12.968

Low Mean Security N SD

5.22 37 3.020

15.51 37 8.211

5.46 37 1.980

26.19 37 11.190

Medium Mean Security N SD

6.94 54 2.543

19.35 54 7.870

6.09 54 2.268

32.39 54 11.273

High Mean Security N SD

10.39 28 1.950

30.71 28 6.765

8.64 28 1.660

49.75 28 9.793

Open

Maximum Possible Scores: Physical =12 Procedural = 42 Skills = 12

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Figure 1 Box—Whisker Plot for Total Security Needs Score 70 60

Security needs total

50 40 30 20 10 0 -10 N=

28

37

54

28

Open

Low

Medium

High

Clinical opinion of best placement

The greatest overlap occurs between low and medium classifications. Overlap may exist because of common characteristics between security settings. The lack of overlap between the high and medium security profiles probably represents the very distinct specifications that exist in high secure provision. The instrument scores provide useful information and general guidance, but as emphasized previously the individual patient profiles need to be examined in terms of a placement that best meets them. A high level of need does not automatically mean a patient requires high security and vice versa, but generally from this study this appears to be the case. Interrater Reliability During the study we obtained dual ratings by Responsible Medical Officer and Primary Nurse on 110 subjects, as we wanted to compare RMO and primary nurse ratings for the same patient, covariance is again a potential problem. Overall security needs scores show strong correlations (agreement) between raters. Conducting a Pearson test gives a correlation coefficient of .732, which is significant at p < 0.01 (two tailed). Conducting the same test separately on

physical, procedural and relational totals all provide significant results at p < 0.01 (two tailed). However, there was also a trend for primary nurses to rate higher than RMOs. Other studies have found differences, for example, Burrow (1993) found the trend to be reversed. This reinforces the idea that needs ratings should be made by consensus between the care team and also points to the need for further development of a user manual for the S.N.A.P. and specific training. Principal Components Analysis The results obtained consist of a large number of variables. The 147 completed instruments resulted in 3234 individual scores (for this part of the analysis we used the 129 RMO and 18 primary nurse ratings detailed earlier). To try and make sense of the large number of possible correlations between variables an exploratory statistical technique called principal components analysis was used. This is a standard technique used in the development of instruments that allows an assessment of the degree to which individual items are measuring the same concept. While the instrument items belong to obvious theoretical subsets of the same dimension (i.e.

Security Needs Assessment

physical, procedural and relational security) we wanted to examine them further for any underlying statistical dimensions that may have further practical utility. Such an analysis will produce a number of factors (items on the instrument that are grouped together). Not all these will be used and we accepted factors with eigen values greater than 1. An eigenvalue indicates the relative importance of the factor and a value over 1 suggests strong importance. Each instrument item receives a loading value for each factor. The highest loading value will then generally be accepted as the factor to which the item belongs. This is better demonstrated in table 3. This shows that 3 factors (described in the following paragraph) were returned with eiganvalues over 1 and shows where the highest loadings for each of the 22 S.N.A.P. items fell. Loadings are expressed as a percentage and the closer to the value of 1 the stronger they are. This table also represents the data after we applied a procedure called varimax rotation. This procedure improves interpretation by strengthening the loading on to the predominant factor. As reliability in this kind of analysis is dependant on sample size there are various suggestions as to the number of subjects in relation to variables. Generally a lower limit of 5 subjects per variable is acceptable and this study works on just over 6 subjects per variable (S.N.A.P. items). The data were also screened prior to applying the procedure. The Kaiser – Meyer – Olkin (KMO) measure and Bartlett’s test were applied. The first test looks at sampling adequacy and the second checks that there are significant relationships between variables. The result of this screening was that a principal component analysis would be appropriate. The loadings in the table are strong; Gaudagnoli and Velicier (1988) argue that if a factor has four or more loadings greater than 0.6 then it is reliable regardless of sample size. Clearly for the first two factors this is the case. However the final factor only has two items but these are strong loadings and, importantly, the items make clinical sense. With an analysis of this type the researchers examine the item groupings to see if they have a rational connection to one another. In this analysis we felt that this was the case and named the factors as follows:

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Factor one: Internal management and protection of others. This contains items related to internal patient management (e.g., nursing intensity and components for the protection of others, which include management of violence and aggression). Factor two: Management of external influence. This contains items strongly related to minimizing/ controlling external influence that may be detrimental or dangerous (as opposed to internal control). For example, the monitoring of external communication and supervision and searching of visitors. Factor three: Notoriety. This only contains two items (and cannot statistically be regarded as a factor) but these have a strong logical connection. A high level of media interest will often necessitate a higher need for security intelligence and police liaison. Conversely, a patient that creates a high level of organizational need for security intelligence and police liaison may often generate media interest. Cronbach’s alphas statistic was utilized to examine the internal consistency of the instrument. This statistic looks at correlation of the items within the factors. Generally a score of over 0.7 indicates reliability. For the first two factors the scores are very strong, 0.94 and 0.90 respectively. It is not appropriate to do such a calculation on the two items in factor 3. The internal consistency of the original items is also strong; using the same statistic, physical security produces a score of 0.92, procedural security 0.93 and relational skills 0.71. Practical Utilization The factors are undoubtedly of clinical relevance, but also require further validation. It is unlikely that our original items would group as factors because they are theoretical domains. Patient characteristics will mean that a combination of physical, procedural and relational items will correlate to produce the best management profile. A total score will be good basic guidance as to level of security need. However we would discourage any undue reliance on scores other than for the purposes of research and instrument development. It is of far more importance to consider the subject being assessed and the possible placement. Can the placement cater to the needs identified? This should be assessed practically by looking at each item in

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Table 3 S.N.A.P. Item Factor Loadings

1 Item 5 Item 21 Item 20 Item 19 Item 2 Item 9 Item 4 Item 1 Item 10 Item 6 Item 3 Item 8 Item 16 Item 17 Item 15 Item 18 Item 12 Item 11 Item 13 Item 7 Item 22 Item 14

Nursing Intensity Response to nursing interventions – Relational skills Relational nursing skills – Relational skills Management of violence and aggression – Relational skills Internal – Physical security Internal movement – Procedural Security Facilities – Physical Security Perimeter – Physical Security Leave – Procedural Security Patient Characteristics Entry – Physical Security Access to potential weapons and fire setting materials – Procedural security Access to alcohol – Procedural security Access to pornographic material – Procedural security Access to illicit substances – Procedural security Access to Information Technology – Procedural security Visitors – Procedural security External communications – Procedural security Visiting children – Procedural security Searching – Procedural security Security intelligence – Relational skills Media exposure – Procedural Security

turn. Unit security provision varies considerably throughout the UK outside of high security, so it will be this that is an important consideration. Using the theoretical items the assessor will be able to say with some degree of certainty what level of physical, procedural and relational security will be needed. The factors currently provide additional useful information in terms of whether the greatest level of need is on factors 1, 2 or 3. Caution should also be noted in the size of the sample in that while respectable it is still relatively small.

Factor 2

3

.809 .735 .678 .675 .671 .664 .658 .574 .569 .562 .538 .537 .799 .743 .714 .697 .650 .544 .536 .533 .806 .718

Missing Data and Nonrelevant Items The scoring system adopted by the S.N.A.P. allows missing data to be treated in two ways. It can be rated as an absence of need in which case there will be no contribution to the overall score. More realistically, clinicians will be cautious and rate higher levels of need if information is inadequate. For example, a patient may not have had the opportunity to go on leave at the time of rating; however, given the level of risk being managed a

Security Needs Assessment

high rating would be necessary. Any items that are not relevant to a particular patient can be rated as zero meaning that the item will make no contribution to any overall score or need profile; for example, pornography often may not be rated. Potential Uses for the S.N.A.P. The primary purpose in developing the S.N.A.P. is to provide a comprehensive instrument to aid experienced forensic clinicians to assess patients’ security needs across a range of security dimensions. The instrument can only be used by experienced clinicians and cannot replace clinical judgment. But we argue that it should guide clinical judgment, and will help to ensure that no relevant variable is ignored. It is hoped that by providing clear and comprehensive definitions of security items, greater agreement can be reached between clinicians and areas of disagreement addressed. The instrument may also aid the design of hospitals. The debate about whether a patient is ‘high’ or ‘medium’ will hopefully move on to one about individual patients’ specific security needs and how best to meet these. We would envisage the S.N.A.P. as being particularly useful at points of transition, e.g., admission to psychiatric services from the criminal justice system or transfer between levels of security. Having a comprehensive description of a patient’s security needs should also assist in drawing up a risk management plan. Such a plan can be dynamic and form a part of regular treatment and risk management reviews. Predominantly the S.N.A.P. is a risk management instrument. Security is provided to manage the risk of harm an individual my pose to others, yet it can often be applied generically, whereby all patients in a particular area are subject to the ‘worst case scenario’ type of approach. While some elements of security cannot be readily adjusted (the perimeter fence for example) others can (level and intensity of searching for example). The provision of detailed descriptors of security can also be used to describe the security provided by an individual unit of service. This can be used to help inform placement decisions by matching patients to units. A further use may be found in providing a framework to assist units in auditing the security they provide. Finally, the provision of detailed and hopefully reliable descriptors of security should be an aid to further

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research, audit and clinical governance in forensic psychiatric services. Planned Developments of SNAP 1. The development of a comprehensive user manual including security descriptors, clinical vignettes for each item and case studies. 2. A National survey of secure units in England to refine the 22 items in relation to actual provision. This study has been outlined by Collins, Davies, and Ashwell (2003) and is supported by a grant from the NHS National Programme on Forensic Mental Health R&D. The work referred to here pre-dates this grant; the views expressed are those of the authors and not necessarily those of the Programme or the Department of Health. 3. Extended clinical studies using the SNAP across low, medium and high secure units (the authors would be pleased to hear from any clinicians interested in utilizing SNAP in clinical practice).

CONCLUSION The increasing size and complexity of forensic psychiatric services has lead to the need to develop a better understanding of the elements of security they provide. The development of the S.N.A.P. intends to aid this by providing comprehensive and clearly described definitions of the elements of security present in secure psychiatric services. Overall S.N.A.P. scores differentiate between clinicians’ opinion of levels of security required and the instrument has encouraging psychometric properties. The S.N.A.P. hopefully has a number of clinical and research applications when used by experienced forensic clinicians. Further development work including a user manual, national survey of secure psychiatric services and evaluation of use in clinical practice is underway.

REFERENCES Abbott, P. (2002). Reconfiguration of the high-security hospitals: some lessons from the mental hospital retraction and reprovision programme in the United Kingdom 1960-2000. Journal of Forensic Psychiatry, 13, 107-122.

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Bartlett, A., Cohen, A., Backhouse, A., Highet, N., & Eastman, N. (1996). Security needs of South West Thames Special Hospital patients: 1992 and 1993. No way out? Journal of Forensic Psychiatry, 7, 256-270. Beck-Sander, A., & Kinsella, C. (1998). Patient selection and management in medium and low security hospitals. Psychiatric Care, 5, 86-91. Burrow, S. (1993). The treatment and security needs of special hospital patients: A nursing perspective. Journal of Advanced Nursing, 18, 1267-1278. Burrow, S. (1994). Therapeutic security and the mentallydisordered offender. British Journal of Nursing, 3, 31415. Coid, J., & Kahtan, N. (2000). An instrument to measure the security needs of patients in medium security. Journal of Forensic Psychiatry, 11, 119-134. Collins, M. (1999). The practitioner new to the role of forensic psychiatric nurse. In D. Robinson & A. Kettles (Eds.), Forensic nursing and the multidisciplinary care of the mentally disordered offender (pp. 39-50). London: Jessica Kingsley. Collins, M., Davies, S., & Ashwell, C. (2003). Meeting patients’ needs in secure forensic psychiatric units. Nursing Standard, 17, 49, 33-34. Davies, S., Collins, M., Hogue, T., Barrs, H., & Eitel–Smith, G. (2001). An audit of the treatment and security needs of Trent patients in secure care with particular reference to the development of long-term medium and low-secure services. In An Audit Report Commissioned by Forensic Services Specialist Commissioning Team (pp. 1-18). North Nottinghamshire Health Authority: United Kingdom. Department of Health. (1993). Design guide: Medium secure psychiatric units. NHS Estates: London. Department of Health. (1999). The National Service framework for mental health. London. Department of Health and Home Office. (2000). Reforming the Mental Health Act. Part II – High Risk Patients, Developing specialist services for those who are dangerous and severely personality disordered. Cm 5016II. London: The Stationary Office. Department of Health. (2002). Mental health policy implementation guide: National minimum standards for general adult services in psychiatric intensive care units (PICU) and low secure environments. London: Department of Health Publications. Exworthy, T., & Gunn, J. (2003). Taking another tilt at high secure hospitals. British Journal of Psychiatry, 182, 469471. Exworthy, T. (2000). Secure psychiatric services. Current Opinion in Psychiatry, 13, 581-585. Guadagnoli, E., & Velicier, W. (1988). Relation of sample size to the stability of component patterns. Psychological Bulletin, 103, 265-275. Kennedy, H. (2002). Therapeutic uses of security: mapping forensic mental health services by stratifying risk. Advances in Psychiatric Treatment 8, 433-443. Kinsley, J. (1992). Security in the special hospitals a special task. London. SHSA.

Kinsley, J. (1998). Security and therapy. In C. Kaye & A. Franey (Eds.), Managing high security psychiatric care (pp. 7584). London: Jessica Kingsley. Maden, A., Curle, C., Meux, C., Burrow, S., & Gunn, J. (1993). The treatment and security needs of patients in special hospitals. Criminal Behaviour and Mental Health, 3, 290306. Mental Health (Care and Treatment) (Scotland) Act (2003). Edinburgh: The Stationary Office. Part 17, Chapter 3. Murray, K., Rudge, S., Lack, S., & Dolan, R. (1994). How many high security beds are needed? Implications from an audit of one region’s special hospital patients. Journal of Forensic Psychiatry, 5, 487-99. Parker, E. (1985). The development of secure provision. In L. Gostin (Ed.), Secure provision (pp. 15-65). London: Tavistock. Pierzchniak, P., Farnham, F., De Taranto, N., Bull, D., Gill, H., Bester, P., McCallum, A., & Kennedy, H. (1999). Assessing the needs of patients in secure settings: A multi-disciplinary approach. Journal of Forensic Psychiatry, 10, 343-354. Reed, J. (1994). Report of the working group on high security and related psychiatric provision. London: Department of Health. Reed, V., Woods, P., & Robinson, D. (2000). Behavioural Status Index (Best-index): A life skills assessment for selecting and monitoring therapy in mental health care. United Kingdom: Psychometric Press. Sayal, K., & Maden, A. (2002). The treatment and security needs of patients in special hospitals: Views of referring and accepting teams. Criminal Behaviour and Mental Health, 12, 244-53. Shaw, J., McKenna, J., Snowden, P., Boyd, C., McMahon, D., & Kilshaw, J. (1994). Clinical features and placement needs of all North West Region patients currently in special hospital. Journal of Forensic Psychiatry 5, 93-106. Shaw, J., Davies, J., & Morley, H. (2001). An assessment of the security, dependency and treatment needs of all patients in secure services in a UK health region. The Journal of Forensic Psychiatry, 12, 610-637. Taylor, P. J., Butwell, M., Dacey, R., & Kaye, C. (1991). Within maximum security hospitals: A survey of need. London: Special Hospitals Service Authority. Taylor, P., Maden, M., & Jones, D. (1996). Long-term mediumsecurity hospital units: a service gap of the 1990’s? Criminal Behaviour and Mental Health, 6, 213-229. Tilt Report. (2000). Report of the review of security at the high security hospitals. London: NHS Executive. Williams, P., Badger, D., Nursten, J., & Woodward, M. (1999) A review of recent academic literature on the characteristics of patients in British special hospitals. Criminal Behaviour and Mental Health, 9, 296-314. Woods, P., Collins, M., & Kettles, A. (2002). Forensic nursing interventions and future directions for forensic mental health practice’. In A. Kettles, P. Woods., & M. Collins (Eds.), Therapeutic interventions for forensic mental health nurses (pp. 240-245). London: Jessica Kingsley.