Frans Fluttert

• Johansen, Kirsten Kjær; Marcussen, Jette; Hansen, Jens Peter; Hounsgaard, Lise & Fluttert, Frans A. J. (2021). Early recognition method for patients with schizophrenia or bipolar disorder in community mental health care: Illness insight, self-management and control. Journal of Clinical Nursing (JCN). ISSN 0962-1067. 31(23-24), p. 3535–3549. doi: 10.1111/jocn.16181. Show summary

  Aims and objective: To investigate how participating in the early recognition method treatment strategy affect illness insight and management, in patients with schizophrenia or bipolar disorder in community mental healthcare. Background: The current practice in mental healthcare focus on shared decision-making and self-managing capacity, but poor insight is a predictor of poor adherence and dropout. Engagement in illness management and recovery predict the treatment response. Design: Semi-structured interviews with a phenomenological-hermeneutic approach. Methods: We conducted 36 semi-structured interviews with 26 patients. The interviews were conducted before and after participating in the intervention using the early recognition method strategy. The analysis was based on Ricoeur's theory of interpretation: Naive reading, structural analysis, interpretation and discussion. The COREQ checklist was used as reporting guideline. Results: The experience of participating in treatment as usual and early recognition method revealed two main themes. The first theme ‘patient care’ describes how dialogue and collaboration increase awareness of the illness and how to gain control. The second theme ‘insight and experience’ describes how illness affects personality and self-image, and how insight entails control and self-confidence. Conclusion: Managing life with severe mental illness is complex and challenging. However, the experience of guidance, support and collaboration between patient and nurse are essential to improve these circumstances. Relevance to clinical practice: A systematic approach to the patient' symptoms, as in the early recognition method strategy, enhances knowledge of the individual patient' symptoms, both for nurse and patient. A knowledge that is significant for meeting individual treatment needs. Therefore, applying this strategy is likely to enhance collaboration and improve treatment outcome.

• Fluttert, Frans A. J.; Eidhammer, Gunnar & Dale, Karl Yngvar (2021). Early recognition method : ‘Opening doors’ in risk management dialogue between mental health and prison services. In Hean, Sarah Catherine Patricia Duff; Johnsen, Berit; Kloetzer, Laure & Kajamaa, Anu (Ed.), Improving interagency collaboration, innovation and learning in criminal justice systems. Supporting offender rehabilitation. Palgrave Macmillan. ISSN 9783030706616. p. 267–295. doi: 10.1007/978-3-030-70661-6_11. Full text in Research Archive
• Johansen, Kirsten Kjær; Hounsgaard, Lise; Hansen, Jens Peter & Fluttert, Frans A. J. (2021). Early Recognition Method - amplifying relapse management in community mental health care : a comprehensive study of the effects on relapse and readmission. Archives of Psychiatric Nursing. ISSN 0883-9417. 35(6), p. 587–597. doi: 10.1016/j.apnu.2021.08.004. Full text in Research Archive Show summary

  This naturalistic multicenter study explored the relationship between participating in the Early Recognition Method (ERM) intervention and relapse, defined as spending at least one night at a psychiatric ward. The intervention was tailored to adult patients with schizophrenia or bipolar disorder in an outpatient mental health care setting. Before the intervention, the staff received training in application of the strategy. The ERM strategy is protocolized and includes identification and monitoring of individual early warning signs and development of a personal plan of action. The study showed a reduction in mean number and duration of readmissions during the period the patients participated in the intervention, compared to an equal pre-intervention period. For patients with bipolar disorder the reduction was statistical significant. The difference in outcome between the two diagnostic groups suggest that further tailoring of the application of the ERM strategy might improve the relapse prevention outcome. Keywords: relapse prevention, community mental health care, early recognition method, risk management strategy, schizophrenia, bipolar disorder

• Gildberg, Frederik Alkier; Fallesen, Janni Petersen; Vogn, Dorit; Baker, John & Fluttert, Frans A. J. (2021). Conflict management : a qualitative study of mental health staff’s perceptions of factors that may influence conflicts with forensic mental health inpatients. Archives of Psychiatric Nursing. ISSN 0883-9417. 35(5), p. 407–417. doi: 10.1016/j.apnu.2021.06.007. Show summary

  Internationally, clinical services are under pressure to reduce their use of restrictive practices. The aim was to explore how mental health nurses and nursing assistants perceive conflict and their use of restrictive practices with mental health inpatients in forensic mental health care. A total of 24 semi-structured interviews with forensic mental health staff were conducted and analysed using thematic analysis. The findings propose a dynamic model that explains how tolerance of potential conflict situations changes depending on individual staff members' perceptions of patients and colleagues, and their relationships. Keywords: professional-patient relations, staff attitude, conflict, violence, qualitative research

• Johansen, Kirsten Kjær; Hounsgaard, Lise; Frandsen, Tove Faber; Fluttert, Frans A.J. & Hansen, Jens Peter (2020). Relapse prevention in ambulant mental health care tailored to patients with schizophrenia or bipolar disorder. Journal of Psychiatric and Mental Health Nursing. ISSN 1351-0126. 28(4), p. 549–577. doi: 10.1111/jpm.12716. Show summary

  Introduction: In recent years, there has been a development in ambulant mental health care towards a more preventive approach, resulting in relapse prevention interventions. Interventions may be patient tailored, to a greater or lesser extent, in relation to the treatment elements included. Aim: To create an overview of non‐pharmacological intervention elements described in relapse prevention interventions for patients with schizophrenia or bipolar disorder based on a systematic review. Method: Six scientific databases were systematically searched. The search strategy, identification and selection of literature complied with the PRISMA statement. Results: Of 7.429 studies screened, 25 were included for analysis. Six treatment elements were identified: Pharmacological treatment, personalized action plan, patient education, patient skills, treatment adherence and family involvement. Discussion: The varying degree of complexity of the interventions indicates that patients with bipolar disorder and schizophrenia have, respectively, different treatment needs. Patients with schizophrenia seem to benefit more from interventions that include support from social network or family than patients with bipolar disorder. More qualitative studies clarifying the patient's perspective on tailored relapse prevention are indicated. Implications for practice: Optimally tailoring relapse prevention for patients with schizophrenia and bipolar disorder will improve treatment outcome, and probably also treatment satisfaction and adherence.

• Fluttert, Frans A. J.; Bjørkly, Stål & Dale, Karl Yngvar (2020). The impact of a discarded diagnosis and focus on early warning signs of aggression on relations between user and municipal service providers : a narrative of a complex case. Current Psychology. ISSN 1046-1310. 41(8), p. 5503–5513. doi: 10.1007/s12144-020-01055-x. Show summary

  By means of a nurse-driven risk management strategy, a community mental health nursing team was assisted in their struggles to cope in the care of a very aggressive and disturbed patient. The aim of this study was to discuss how a wrong diagnosis lead to relational consequences in care and how applying the Early Recognition Method (ERM) contributed to a relational change. Self psychology concepts were used to analyze and understand the underlying psychological process in the interaction between the nurses and patient. This case narrative illustrates qualitative research strategies through the lens of the theoretical framework of symbolic interactionism. Nurses gained a better understanding of the complexity of the patient and the nature and effects of their interactions with her. The patient’s diagnosis was adjusted, resulting in perspectives that allowed for meaningful interactions and stabilization of aggressive behaviors. The most prominent result was the nurses becoming more confident and competent in their management of the care process. Nurses in community mental health care benefit from structured risk management strategies in unraveling the complexity of severe aggression. Self psychology is a meaningful lens by which to better understand the underlying psychological process in the interaction between nurses and a complex patient.

• Eidhammer, Gunnar; Fluttert, Frans A. J. & Bjørkly, Stål (2014). User involvement in structured violence risk management within forensic mental health facilities : a systematic literature review. Journal of Clinical Nursing (JCN). ISSN 0962-1067. 23(19-20), p. 2716–2724. doi: 10.1111/jocn.12571. Show summary

  Aims and objectives: To examine empirical literature on user involvement in collaboration between patients and nurses. The scope of the review was limited to structured violence risk management interventions in forensic mental health settings. Background: Violence in forensic mental health settings represents a significant problem for patients and staff. Structured violence risk management interventions in forensic mental health have been reported to ignore patient participation, despite the growing attention on user involvement in clinical practice. Design: A systematic review. Method: Searches were conducted in six databases: the Cochrane Systematic Reviews, MEDLINE, CINAHL, ProQuest, ScienceDirect and PsycINFO. Papers were assessed according to a predetermined set of inclusion and exclusion criteria. Results: After searches of the reference lists of retrieved articles were conducted, only three papers met the inclusion criteria. Conclusions: This review has shown that empirical research on the topic of risk management interventions in which patients are involved is scarce. Relevance to clinical practice: There is barely any research evidence of the clinical effect of user involvement approaches on violence risk management in forensic mental health practice. Therefore, we suggest that clinicians may learn from positive experiences concerning user involvement in general psychiatry and carefully adapt and test them out in the forensic treatment context.

• Fluttert, Frans A. J.; Van Meijel, Berno; Bjørkly, Stål; Van Leeuwen, Mirjam & Grypdonck, Mieke (2013). The investigation of early warning signs of aggression in forensic patients by means of the ‘Forensic Early Signs of Aggression Inventory’. Journal of Clinical Nursing (JCN). ISSN 0962-1067. 22(11-12), p. 1550–1558. doi: 10.1111/j.1365-2702.2012.04318.x. Show summary

  Aims and objectives: The Forensic Early Warning Signs of Aggression Inventory (FESAI) was developed to assist nurses and patients in identifying early warning signs and constructing individual early detection plans (EDP) for the prevention of aggressive incidents. The aims of this research were as follows: First, to study the prevalence of early warning signs of aggression, measured with the FESAI, in a sample of forensic patients, and second, to explore whether there are any types of warning signs typical of diagnostic subgroups or offender subgroups. Background: Reconstructing patients’ changes in behaviour prior to aggressive incidents may contribute to identify early warning signs specific to the individual patient. The EDP comprises an early intervention strategy suggested by the patient and approved by the nurses. Implementation of EDP may enhance efficient risk assessment and management. Design: An explorative design was used to review existing records and to monitor frequencies of early warning signs. Methods: Early detection plans of 171 patients from two forensic hospital wards were examined. Frequency distributions were estimated by recording the early warning signs on the FESAI. Rank order correlation analyses were conducted to compare diagnostic subgroups and offender subgroups concerning types and frequencies of warning signs. Results: The FESAI categories with the highest frequency rank were the following: (1) anger, (2) social withdrawal, (3) superficial contact and (4) non-aggressive antisocial behaviour. There were no significant differences between subgroups of patients concerning the ranks of the four categories of early warning signs. Conclusion. The results suggest that the FESAI covers very well the wide variety of occurred warning signs reported in the EDPs. No group profiles of warning signs were found to be specific to diagnosis or offence type. Relevance to clinical practice: Applying the FESAI to develop individual EDPs appears to be a promising approach to enhance risk assessment and management.

• Fluttert, Frans A. J.; Van Meijel, Berno; Van Leeuwen, Mirjam; Bjørkly, Stål; Nijman, Henk & Grypdonck, Mieke (2011). The Development of the Forensic Early Warning Signs of Aggression Inventory: Preliminary findings: Toward a Better Management of Inpatient Aggression. Archives of Psychiatric Nursing. ISSN 0883-9417. 25(2), p. 129–137. doi: 10.1016/j.apnu.2010.07.001. Show summary

  Objective “Early warning signs of aggression” refers to recurring changes in behaviors, thoughts, perceptions, and feelings of the patient that are considered to be precursors of aggressive behavior. The early recognition of these signs offers possibilities for early intervention and prevention of aggressive behaviors in forensic patients. The Forensic Early warning Signs of Aggression Inventory (FESAI) was developed to assist nurses and patients in identifying and monitoring these early warning signs of aggression. Methods The FESAI was developed by means of qualitative and quantitative strategies. One hundred seventy six early detection plans were studied to construct a list of early warning signs of aggression. Inventory drafting was done by merging and categorizing early warning signs. Forensic nursing professionals assessed face validity, and interrater agreement was tested. Results The investigation of early detection plans resulted in the FESAI, which contains 44 early warning signs of aggression subdivided into 15 main categories. The face validity of the form was very good, and the interrater agreement was satisfactory. Conclusions Preliminary findings indicate that the FESAI provides a useful listing of early warning signs of aggression in forensic patients. It may facilitate the construction of early detection plans for the prevention of aggressive behaviors in forensic psychiatry.

• Fluttert, Frans A. J.; Van Meijel, Berno; Nijman, Henk; Bjørkly, Stål & Grypdonck, Mieke (2010). Preventing aggressive incidents and seclusions in forensic care by means of the 'Early Recognition Method'. Journal of Clinical Nursing (JCN). ISSN 0962-1067. 19(11-12), p. 1529–1537. doi: 10.1111/j.1365-2702.2009.02986.x. Show summary

  OBJECTIVE. The Early Recognition Method aims at improving collaboration between nurses and patients to prevent aggression in forensic psychiatric care. To achieve this goal, Early Recognition Method strongly focuses on early signs of aggression. In the current study, we investigated whether application of Early Recognition Method led to a significant decrease in inpatient incidents. BACKGROUND. Nurses in forensic settings are often confronted with patients' aggression. Better collaboration between nursing staff and patients may improve patients' ability to self manage aggression and contribute to a decrease in inpatient aggression. DESIGN. Naturalistic one-way case-crossover design. METHODS. The Early Recognition Method was introduced on 16 wards of a maximum security forensic hospital. Using a one-way case-crossover design, where cases were their own controls, the effects of Early Recognition Method were assessed by comparing the number of incidents of 189 patients during "Treatment As Usual" with the period after Early Recognition Method was implemented. The Early Recognition Method intervention involved weekly evaluations of signs of aggression between staff and patients. The outcome measures were the number of seclusions and the severity of inpatient incidents. RESULTS. A significant decline in the number of seclusions was observed after Early Recognition Method was introduced. Apart from this decrease, the mean severity of inpatient incidents was also found to be lower during the post intervention period. The effect size was most pronounced for patients with substance abuse and personality disorders. Patients with schizophrenia, however, showed modest, yet significant, effect sizes. CONCLUSIONS. The results suggest that Early Recognition Method may be an innovative and effective risk management method for forensic psychiatric patients, in particular for patients with personality disorders. RELEVANCE TO CLINICAL PRACTICE. This article aims to contribute to evidence-based risk management for nurses in collaboration with their patients, resulting in a decrease in inpatient aggression.

• Fluttert, Frans A. J.; Van Meijel, Berno; Nijman, Henk; Bjørkly, Stål & Grypdonck, Mieke (2010). Detached Concern of Forensic Mental Health Nurses in Therapeutic Relationships With Patients: The Application of the Early Recognition Method Related to Detached Concern. Archives of Psychiatric Nursing. ISSN 0883-9417. 24(4), p. 266–274. doi: 10.1016/j.apnu.2009.09.002. Show summary

  OBJECTIVE: Improvement of the interaction between forensic mental health nurses and patients may lead to a reduction of inpatient violence. The concept under study is detached concern, which refers to nurses' skills to neutralize the emotional appeal of patients by a balanced attitude between objectivity and emotional involvement. The Patient Contact Questionnaire (PCQ) aims at measuring the degree of concern of nurses for their patients. METHODS: The PCQ was applied in a pretestposttest design, evaluating the effects of the Early Recognition Method (ERM). This method aims at the prevention of inpatient violence in forensic psychiatry. Subjects were 116 forensic mental heath nurses working on 16 wards of a large Dutch forensic hospital. First, the baseline scores were compared to scores reported in an earlier study conducted in general psychiatry. Second, pretestposttest comparisons were carried out for all nurses, and for subgroups of nurses with regard to gender, educational level, years of working experience, and patient population. Third, pretestposttest comparisons were made on the PCQ item level. RESULTS: The baseline scores of male nurses indicated significantly higher levels of concern than those of female nurses. In addition, more experienced nurses scored significantly higher with regard to concern than less experienced nurses. When comparing the scores before and after applying ERM,

• Fluttert, Frans A. J.; Van Meijel, Berno; Nijman, Henk; Bjørkly, Stål & Grypdonck, Mieke (2008). Die Resultate einer Studie zur Früherkennung von Gewaltsituationen. In Saimeh, Nahlah (Eds.), Zukunftswerkstatt Maßregelvollzug. Psychiatrie-Verlag. ISSN 978-3-88414-461-9. p. 79–86. Show summary

  Ziel der Methode ist die Entwicklung/Förderung der Selbstmanagementfähigkeiten der Patienten hinsichtlich der Rückfallprävention von Gewalt. Pflegende und Patienten besprechen, beschreiben und beobachten die Frühwarnzeichen für risikoreiches Verhalten. In den Niederlanden kam die Intervention bei 189 Maßregelvollzugspatienten zum Einsatz. Die Studie dauerte 30 Monate. Ein quasi-experimentelles Design mit zeitverzõgerte Implementierung der Intervention wurde gewählt. Hauptzielvariablen waren die Schwere der Gewalt sowie die Anzahl der Isolierungen. Die Ergebnisse zeigen unter anderem einen signifikanten Rückgang von Isolierungen und von schweren Gewaltereignissen bei Patienten, die mit der Methode arbeiten, vergleichen mit den Patienten unter >care as usual<-Bedingungen. Der effekt war bei Patienten mit Persönlichkeitsstörungen äußerst bemerkenswert.

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• Hassiotis, Angela; Almvik, Roger & Fluttert, Frans A. J. (2022). Coercion as a response to violence in mental health-care settings. The Lancet. ISSN 0140-6736. 9(1), p. 6–8. doi: 10.1016/S2215-0366(21)00476-4.
• Fluttert, Frans A. J. & Van Mesdag, S. (2021). FMH-nursing risk formulaton and the ‘onward flight’ of the early recogniton method. IAFMHS Newsletter. 6(1-2), p. 9–10.
• Fluttert, Frans A. J.; Van Mesdag, S.; van Leuwen, Mirjam & Van Meijel, Berno (2016). Agressie in de forensische zorg : ERM-­‐vroegsignalering en management van delict-­‐gevaarlijkheid. In Van Meijel, Berno (Eds.), Ggz-verpleegkunde in de praktijk. Tijdstroom, Uitgeverij De. ISSN 9789058982971.
• Fluttert, Frans A. J. (2016). Risicobeheersing en zelfmanagement via kwetsbare patronen van gedragsontregeling. In Menger, Anneke; Krechtig, Lous & Bosker, Jacqueline (Ed.), Werken in gedwongen kader : methodiek voor het forensisch sociaal werk. Uitgeverij SWP. ISSN 9789088504242. p. 339–352.
• Fluttert, Frans A. J.; Eidhammer, Gunnar; Friestad, Christine; Dale, Karl Yngvar; Bjørkly, Stål & Rustad, Åse-Bente L (2015). The Early Recognition Method used to identify precursors of aggression in prisoner. In Callaghan, Patrick; Oud, Nico; Bjørngaard, Johan Håkon; Nijman, Henk; Palmstierna, Tom & Duxbury, Joy (Ed.), Violence in Clinical Psychiatry : Proceedings of the 9th European Congress on Violence in Clinical Psychiatry, 22 – 24 October 2015 Crowne Plaza Copenhagen Towers. Kavanah, Dwingeloo & Oud Consultancy. ISSN 978-90-574-0144-2. p. 313–314.
• Fluttert, Frans A. J.; Eidhammer, Gunnar; Friestad, Christine; Dale, Karl Yngvar; Bjørkly, Stål & Rustad, Åse-Bente L (2015). The Early Recognition Method used to identify precursors of aggression in prisoner.
• Fluttert, Frans A. J.; Van Meijel, Berno; Van Leeuwen, Mirjam; Bjørkly, Stål; Nijman, Henk & Grypdonck, Mieke (2011). The development and application of the Forensic Early Signs of Aggression Inventory in forensic care.
• Fluttert, Frans A. J.; Van Meijel, Berno; Nijman, Henk; Bjørkly, Stål & Grypdonck, Mieke (2009). Die Methode der Frühwarnsignale in der Prävention von Risikoverhalten. SCHIZOPHRENIE Beiträge zu Forschung,Therapie und psychosozialem Management. ISSN 0938-2720. 25(Oktober 2009), p. 34–43. Show summary

  Die Schlüsselvariable im Management von Aggression während einer Behandlung in einem geschlossenen Setting, ist die Interaktion zwischen den Pflegenden und dem Patient. Aus dieser Perspektive heraus wurde die Methode der Früherkennung entworfen, bei der die Pflegenden lernen, die frühen Signale von Risikoverhalten zu erkennen und ihr Verhalten darauf einzustellen. In FPC Dr. S. Van Mesdag / Forint, einer forensisch-psychiatrischen Klinik in Groningen/Niederlande war die Methode der Frühwarnsignale Gegenstand einer Untersuchung. Innerhalb von zwei-einhalb Jahren sind alle pflegerischen Mitarbeiter in dieser Methode ausgebildet worden. Die Methode wurde auf alle 189 Patienten angewandt. Die wichtigste Ergebnisvariable war das Auftreten aggressiver Zwischenfälle. In einem "Naturalistic one-way case-crossover Design" war es möglich für jeden Patienten das Auftreten von solchen Zwischenfällen, mit und ohne Intervention, zu analysieren. Die Ergebnisse bei Anwendung dieser Methode zeigen eine signifikante Ab- nahme der Anzahl wie der Schwere der Vorfälle. Dies führte zu dem "Platypus Project": einer internationalen Multi-Center-Forschung an 5 forensischen Kliniken aus den Niederlanden, Deutschland und Schweden.

• Eidhammer, Gunnar; Fluttert, Frans A. J.; Knutzen, Maria & Bjørkly, Stål (2013). Early Recognition Method - ERM : Pilotfase 2 - 2009-2013. Kompetansesenter for sikkerhets-, fengsels- og rettspsykiatri. Helseregion Sør-Øst. ISSN 978-82-8227-021-2. Show summary

  Denne rapporten redegjør for erfaringer med bruk av Early Recognition Method i Norge årene 2009 – 2013. ERM ble innført i høsten 2008 ved psykiatrisk avdeling Lier som ett pilotprosjekt, som ble avsluttet høsten 2009 med en egen prosjektrapport. Styringsgruppen i prosjektet besluttet å videreføre pilotprosjektet til en pilotfase 2, for ytterligere kliniske erfaringer med ERM i Norge. Hoved erfaringene er at ERM kan benyttes sammen med pasienter ved sikkerhetsavdelinger så vel som ute i kommuner. Det ble gjort erfaringer med at ERM er virksomt og positivt i samhandling mellom tjenestenivåer og at særlig fokus på brukermedvirkning var positivt. Gjennom pilotfase 2, ble flere institusjoner introdusert for metoden og det ble blant annet etablert samarbeid med Stavanger. Dette samarbeidet har blant annet munnet ut i en mastergradpublikasjon. Et annet viktig arbeid har vært å oversette, tilpasse og utvikle ERM dokumenter til norsk. Emneord: Early Recognition Method, ERM, psykisk helsevern, voldsrisikohåndtering, samhandling, brukermedvirkning, miljøterapi.

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