The Management of Aggression and Violence Attitude Scale (MAVAS): a cross-national comparative study

Educational programs and interventions for health care staff to prevent and manage aggressive behaviors in acute hospitals: a systematic review

OBJECTIVE

The objective of this review was to determine the effect of educational programs that have been implemented in acute health care settings to manage or prevent aggressive behaviors toward staff perpetrated by patients, families, or visitors.

INTRODUCTION

Health care staff working within acute-level and tertiary-level hospitals are at high risk of exposure to aggressive behaviors by patients, their family, or visitors. Negative staff and organizational impacts reported in the literature include individual psychological or emotional distress and severe harm, increased absenteeism, high staff turnover, and awarded compensation. Reports of this kind of occupational violence are increasing globally; therefore, strategies to address prevention and management are needed to mitigate the risk of harm to staff and the wider hospital service. Various educational activities have been implemented to address the issue, but the overall effect of these is unclear.

INCLUSION CRITERIA

Experimental and quasi-experimental studies were considered for inclusion if they reported on an educational program or intervention for staff working within an acute hospital setting and aimed at managing or preventing occupational violence perpetrated by patients, family, or visitors. Reports of programs implemented to address occupational violence, whether verbal or physical, were included. Studies were excluded if they reported on upward violence or bullying, patients in psychiatric or dementia facilities, or pediatric patients, due to the specific care needs of these cohorts.

METHODS

The following databases were searched: PubMed (PubMed Central), CINAHL (EBSCOhost), PsycINFO (EBSCOhost), Embase, ERIC (ProQuest), Cochrane Central Register of Controlled Trials (Cochrane Library), and Scopus. ProQuest Dissertations and Theses was searched for unpublished studies. To obtain a wider perspective of the issue, studies published in Chinese were also searched in WanFang Database, China National Knowledge Infrastructure, and Chongqing VIP. A date filter of 2008-2023 was applied in a deliberate effort to expand from previous work. No language filters were applied. The review was conducted in accordance with JBI methodology for systematic reviews of effectiveness, and reported as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

The search process retrieved 4681 citations. A total of 32 studies representing 3246 health staff were included in the review. The studies were either before-and-after or pre-test/post-test study designs. Methodological quality of studies varied, with the main issues being absence of CIs within statistical analysis, limited detail on participant selection or attrition/non-response, and underreporting of confounding factors. Educational programs varied in content and duration. Content delivery across the studies also varied, with several didactic, role-play, debriefing, group work, and simulation exercises reported. While studies reported some improvement in self-reported confidence levels, results were mixed for other outcomes. Determining overall effect of included studies was challenging due to heterogeneity within and across studies with regard to intervention types, populations, measurement tools, and outcomes.

CONCLUSIONS

This review is unable to determine which workplace educational programs had an effect on staff outcomes or on the number of occupational violence incidents. In the future, educators and researchers could use the findings of this review to guide the design of educational programs and employ measures that are comparable to their settings.

REVIEW REGISTRATION

PROSPERO CRD42020190538.

SUPPLEMENTAL DIGITAL CONTENT

A Chinese-language version of the abstract of this review is available [ http://links.lww.com/SRX/A33 ].

Nurses', patients', and informal caregivers' attitudes toward aggression in psychiatric hospitals: A comparative survey study

Attitudes toward aggression is a controversial phenomenon in psychiatry. This study examined and compared attitudes toward patient aggression in psychiatric hospitals from the perspectives of nurses, patients and informal caregivers and identified factors associated to these attitudes. A total of 2,424 participants completed a self-reported instrument regarding attitudes toward aggression (12-items Perception of Aggression Scale; POAS-S). We analysed data from nurses (n = 782), patients (n = 886), and informal caregivers (n = 765). Pearson's r correlations were used to examine associations between variables. Differences between group scores were analysed using ANOVA/MANOVA with post-hoc Sheffe tests. Multivariate logistic regression models and logistic regression analysis were used to examine the effects of respondents' characteristics on their attitudes toward aggression. Nurses had significantly more negative and less tolerant perceptions toward aggression (mean [SD] 47.1 [7.5], p<0.001) than the patients (mean [SD] 44.4 [8.2]) and the informal caregivers (mean [SD] 45.0 [6.9), according to the POAS-S total scores. The same trend was found with the dysfunction and function sub-scores (mean [SD] 25.3 [4.1] and 15.0 [3.6], respectively); the differences between the groups were statistically significant (p <0.001) when nurses' scores were compared to those of both the patients (mean [SD] 23.7 [5.3] and 14.0 [4.1], respectively) and the informal caregivers (mean [SD] 24.4 [4.2] and 13.9 [3.5], respectively). The study offers new understanding of aggressive behavior in different treatment settings where attitudes toward patient behavior raises ethical and practical dilemmas. These results indicate a need for more targeted on-the-job training for nursing staff, aggression management rehabilitation programs for patients, and peer-support programs for informal caregivers focused on patient aggression.

Healthcare professionals' and patients' attitudes toward the causes and management of aggression in Estonian psychiatric clinics: a quantitative cross-sectional comparative study

BACKGROUND

To enhance patient aggression management efficacy and to reduce the use of coercive interventions in inpatient psychiatric care, it is important to know the attitudes of all involved parties towards the aggression and its management.

AIMS

This study aimed to explore attitudes of the psychiatrists, nurses and inpatients toward the causes and management of patient aggression in Estonian psychiatric clinics. A frequency of aggressive behaviour experienced by professionals, the relationships between the attitudes, participation in coercion, and a frequency of aggression, were also identified.

METHODS

To assess attitudes towards the causes and management of patient aggression, the Management of Aggression and Violence Attitude Scale was implemented.

RESULTS

The survey comprised of 63 psychiatrists, 197 nurses and 199 inpatients. The patients and the professionals had similar as well as different attitudes toward aggression and its management. Patients expected professionals to take a more personal approach when aggression occurs; in some cases, allowing the patients to deal with negative emotions on their own but, if necessary, isolating or restraining the violent people.

CONCLUSIONS

There is a need of training programs that focus on dealing patient aggression to foster a culture of safe, patient-centred care and to reduce aggression in psychiatric clinics.

The Model for Understanding Inpatient Aggression: A Version for Mental Health Nurses Working in Prisons

Preventing and managing aggression remains an important and challenging task for mental health nurses. Despite the concern, there is a dearth of frameworks to assist practice and inform assessment and intervention related to aggression, for forensic mental health nurses working in prisons. This paper presents a model for understanding aggression within prison mental health units. The model elucidates various personal and situational determinants of aggression. It offers a systematic framework for mental health nurses to investigate and understand aggression, to ultimately assist nurses to provide care in an informed and effective manner, and for services to consider structural factors that contribute to the risk of aggression.

[Cologne Questionnaire on Attitudes Towards Coercive Measures (KEZ)]

OBJECTIVE

To develop a psychometric instrument for the assessment of the attitude of psychiatric staff towards the use of coercion.

METHODS

Based on a literature search, interviews (37 open questions) were carried out by representatives each of doctors and nurses. A first version was developed, all doctors and nurses in a psychiatric clinic were asked to answer the questionnaire anonymously.

RESULTS

226 employees took part (response rate 32.3 %). A test-theoretical analysis led to a 39 item set with a high consistency of the overall scale (Cronbach's α =0 .904) and three factors: 1) Acceptance of coercive measures without questioning (Cronbach's α = 0.797); 2) Meaningfulness and legitimation of coercive measures (Cronbach's α = 0.812); and 3) Security and order through coercive measures (Cronbach's α = 0.791).

CONCLUSIONS

With the KEZ an instrument is available that holistically presents the various aspects of the attitudes of psychiatric staff to the use of coercion.

Conceptual framework for a comprehensive competence in managing challenging behaviour: The views of trained instructors

WHAT IS KNOWN ON THE SUBJECT?: There is body of knowledge available about the harms associated with restrictive interventions used in behaviour management, service users' perceptions of the use of restraints, and staff competence in behaviour management. The staff perspective has been studied in terms of staff exposure, responses to and prevention of aggression, staff-related factors associated with service user aggression, and staff attitudes and perceptions towards violence. The definitions of competence in behaviour management provided in training interventions are fragmented and based on unilateral measurements. Training interventions with the purpose of enhancing staff competence in behaviour management are organized regularly, yet there is a lack of clarity on how effective these interventions are. Inadequate conceptual understanding of behaviour management can weaken the effectiveness of these interventions. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Our study produced new knowledge by providing a preliminary conceptual framework that can be used to comprehensively describe and assess competence in managing challenging behaviour and to cover safely the whole care process. Humane care and ethical sensitivity should be the premises of interaction with people in distress. We also pointed out the needs for conceptual clarification of the concepts of confidence, support and restraint. We provide important new insight into the leadership and cultural issues of behaviour management that is relevant for patients, staff members and healthcare organizations. We found that staff members do not consider service user safety and workplace safety as opposing issues. Further, we provide new perspectives for prevention, the risk assessment process and effective communication in the context of behaviour management. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: A comprehensive understanding of the competences related to behaviour management will foster universal definitions for "support" and "restraint," which can then be used to ensure that the best practices are used for behaviour management. Organizational culture and participative leadership on behaviour management should be developed with a special focus on safety issues, common understanding of comprehensive competence, risk assessment and prevention, views regarding the use of restraints, and teamwork. ABSTRACT: Introduction Previous research concerning staff views of behaviour management has not considered instructors' views. The definitions of competence in behaviour management are fragmented, which can undermine the effectiveness of training interventions. Aim/Question This study aimed to describe Finnish and British Management of Actual or Potential Aggression instructors' perceptions of safety and behaviour management-related competences and create a conceptual framework for comprehensive competence. Method An explorative-descriptive qualitative approach with purposive sampling (N = 22), semi-structured interviews and abductive content analysis. Results Conceptual framework of comprehensive competence in managing challenging behaviour includes five categories-knowledge, skills, attitude, confidence and ethical sensitivity-and 21 subcategories. Competent staff and supportive leadership ensured safety, while inconsistent risk management culture, the health and behaviour of service users, and inadequate staff orientation endangered safety. Discussion The study produced new knowledge of safety issues and competences from the perspective of the instructors who deliver behaviour management training. Implications for practice Competence to manage challenging behaviour should be developed based on our conceptual framework to provide an effective and safe training. Prevention, the risk assessment process, alternative communication, and the definitions of "confidence," "support" and "restraint" should all be sufficiently addressed in future training.

Effectiveness of educational interventions for health care staff to prevent and manage aggressive behaviors in patients admitted to an acute hospital: a systematic review protocol

OBJECTIVE

The objective of this review is to determine the most effective strategies for educating health care staff to manage or prevent aggressive patient behaviors within an acute care setting.

INTRODUCTION

Health care workers in acute settings are frequently at risk of being injured by aggressive patients. Staff are often ill-prepared to de-escalate such behaviors and, therefore, are at greater exposure to verbal or physical injury. This protocol outlines methods for a systematic review on the effectiveness of educational strategies to manage and/or prevent aggressive patient behaviors in hospitals.

INCLUSION CRITERIA

Quantitative studies that report on programs used to educate or train hospital staff in managing or preventing an episode of aggressive behavior by an adult patient while in an acute health care facility will be included. Individual, program, and organizational outcomes, such as confidence, behavior, knowledge, or attitudes, as well as recorded rates of injury, sick leave, stress, anxiety, or detection/prevention of aggression before and/or after the intervention will be analyzed. Psychiatric patients or settings are excluded from this review.

METHODS

Two reviewers will independently select and appraise eligible studies and extract data following methods outlined by JBI for systematic reviews of effectiveness. Multiple databases will be searched for studies in English and Chinese from 2008 to the present. The JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI) will be used to manage studies and, where possible, meta-analysis will be undertaken. Results will be presented in a Summary of Findings following the GRADE approach.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020190538.

Education and training for preventing and minimizing workplace aggression directed toward healthcare workers

BACKGROUND

Workplace aggression constitutes a serious issue for healthcare workers and organizations. Aggression is tied to physical and mental health issues at an individual level, as well as to absenteeism, decreased productivity or quality of work, and high employee turnover rates at an organizational level. To counteract these negative impacts, organizations have used a variety of interventions, including education and training, to provide workers with the knowledge and skills needed to prevent aggression.  OBJECTIVES: To assess the effectiveness of education and training interventions that aim to prevent and minimize workplace aggression directed toward healthcare workers by patients and patient advocates.

SEARCH METHODS

CENTRAL, MEDLINE, Embase, six other databases and five trial registers were searched from their inception to June 2020 together with reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

Randomized controlled trials (RCTs), cluster-randomized controlled trials (CRCTs), and controlled before and after studies (CBAs) that investigated the effectiveness of education and training interventions targeting aggression prevention for healthcare workers.

DATA COLLECTION AND ANALYSIS

Four review authors evaluated and selected the studies resulting from the search. We used standard methodological procedures expected by Cochrane. We assessed the certainty of evidence using the GRADE approach.

MAIN RESULTS

We included nine studies-four CRCTs, three RCTs, and two CBAs-with a total of 1688 participants. Five studies reported episodes of aggression, and six studies reported secondary outcomes. Seven studies were conducted among nurses or nurse aides, and two studies among healthcare workers in general. Three studies took place in long-term care, two in the psychiatric ward, and four in hospitals or health centers. Studies were reported from the United States, Switzerland, the United Kingdom, Taiwan, and Sweden. All included studies reported on education combined with training interventions. Four studies evaluated online programs, and five evaluated face-to-face programs. Five studies were of long duration (up to 52 weeks), and four studies were of short duration. Eight studies had short-term follow-up (< 3 months), and one study long-term follow-up (> 1 year). Seven studies were rated as being at "high" risk of bias in multiple domains, and all had "unclear" risk of bias in a single domain or in multiple domains. Effects on aggression Short-term follow-up The evidence is very uncertain about effects of education and training on aggression at short-term follow-up compared to no intervention (standardized mean difference [SMD] -0.33, 95% confidence interval [CI] -1.27 to 0.61, 2 CRCTs; risk ratio [RR] 2.30, 95% CI 0.97 to 5.42, 1 CBA; SMD -1.24, 95% CI -2.16 to -0.33, 1 CBA; very low-certainty evidence). Long-term follow-up Education may not reduce aggression compared to no intervention in the long term (RR 1.14, 95% CI 0.95 to 1.37, 1 CRCT; low-certainty evidence). Effects on knowledge, attitudes, skills, and adverse outcomes Education may increase personal knowledge about workplace aggression at short-term follow-up (SMD 0.86, 95% CI 0.34 to 1.38, 1 RCT; low-certainty evidence). The evidence is very uncertain about effects of education on personal knowledge in the long term (RR 1.26, 95% CI 0.90 to 1.75, 1 RCT; very low-certainty evidence). Education may improve attitudes among healthcare workers at short-term follow-up, but the evidence is very uncertain (SMD 0.59, 95% CI 0.24 to 0.94, 2 CRCTs and 3 RCTs; very low-certainty evidence). The type and duration of interventions resulted in different sizes of effects. Education may not have an effect on skills related to workplace aggression (SMD 0.21, 95% CI -0.07 to 0.49, 1 RCT and 1 CRCT; very low-certainty evidence) nor on adverse personal outcomes, but the evidence is very uncertain (SMD -0.31, 95% CI -1.02 to 0.40, 1 RCT; very low-certainty evidence). Measurements of these concepts showed high heterogeneity.

AUTHORS' CONCLUSIONS

Education combined with training may not have an effect on workplace aggression directed toward healthcare workers, even though education and training may increase personal knowledge and positive attitudes. Better quality studies that focus on specific settings of healthcare work where exposure to patient aggression is high are needed. Moreover, as most studies have assessed episodes of aggression toward nurses, future studies should include other types of healthcare workers who are also victims of aggression in the same settings, such as orderlies (healthcare assistants). Studies should especially use reports of aggression at an institutional level and should rely on multi-source data while relying on validated measures. Studies should also include days lost to sick leave and employee turnover and should measure outcomes at one-year follow-up. Studies should specify the duration and type of delivery of education and should use an active comparison to prevent raising awareness and reporting in the intervention group only.

Short-term PsychoEducation for Carers To Reduce Over Medication of people with intellectual disabilities (SPECTROM): study protocol

INTRODUCTION

Psychotropic medications that are primarily licenced for the treatment of psychiatric disorders are used widely (32%-85%) among people with intellectual disabilities (ID) often for the management of problem (challenging) behaviour in the absence of a psychiatric disorder. Care staff play a pivotal role in the prescribing process. Currently, no staff training programme exists to address the issue of overprescribing of psychotropic medication in people with ID, thus highlighting an urgent need for developing a psychoeducational programme (PEP) specifically designed to address this issue. We propose to develop a PEP for care staff using the methodology described in the UK Medical Research Council guide for complex interventions.

METHODS AND ANALYSIS

The development of the PEP will involve (1) gathering information on available relevant training programmes, (2) running four focus groups with care staff and other professionals to establish the content and format of the PEP, and (3) organising a co-design event involving all relevant stakeholders to discuss the format of the PEP. A core project team will develop the PEP under guidance from the PEP Development Group which will consist of 10-12 relevant stakeholder representatives. Feedback from selected stakeholders on a draft PEP will allow us to refine the PEP before implementation. The PEP will have web-based modules supplemented by face to face training sessions. When the final draft is ready, we will field test the PEP on six to eight care staff from community care homes for people with ID. After completing the field test, we will run a focus group involving participants in the PEP to get feedback on the PEP.

ETHICS AND DISSEMINATION

Ethics approval for this study was waived by the UK Health Regulatory Authority as the study does not collect any patient related information and only include care staff outside the UK NHS. This will be the first ever such universally freely available PEP supported by training manual and slides.

Patient-on-Staff Assaults: Perspectives of Mental Health Staff at an Acute Inpatient Psychiatric Teaching Hospital in the United States

INTRODUCTION

Physical assaults perpetrated by patients in psychiatric hospitals against mental health staff (MHS) is a serious concern facing psychiatric hospitals. Assaulted staff reports physical and psychological trauma that affects their personal and professional lives. There is a dearth of literature exploring this phenomenon.

PURPOSE

To explore MHS perspectives of assault by psychiatric patients.

METHODS

A transcendental phenomenological qualitative design was used to explore and analyze the perspectives of a purposeful sample of 120 MHS perspectives at an acute inpatient psychiatric hospital. Participants' age ranged from 22 to 63 years (mean age = 32.4). Moustakas' theoretical underpinnings guided the study.

RESULTS

Two patterns, 8 themes, and 19 subthemes were identified: (a) Psychological impacts revealed four themes-increase of anxiety/fear level, helplessness and hopelessness, flashbacks/burnout, and doubting own competency. (b) Physiosocial impacts revealed four themes-unsupportive superiors, stigmatization of staff victim, failure to report the incident, and environmental safety.

DISCUSSION

Participants verbalized that assaults by patients have instilled fear and trauma in them. Most of the assaults occurred when staff were performing their routine job functions and setting limits to patient's behavior.

CONCLUSION

The study allowed MHS opportunities to narrate their lived experiences of being assaulted by patients and provided validation of their perspectives. Findings illuminated the phenomenon and may help to support policy changes in psychiatric hospitals.

The outcome of a training programme (RESPECT) on staff's attitudes towards causes and management of aggression in a Regional Referral Hospital of northern Uganda

WHAT IS KNOWN ON THE SUBJECT?: Health systems in many low- to middle-income countries (LMICs) are heavily underfunded, and staff training opportunities are limited. There is a lack of empirical data on the development and use of sustainable training programmes in aggression management skills in LMICs. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: After RESPECT, participants showed greater agreement with statements about the role of environmental and relational factors as antecedents of aggression and described favouring the use of non-physical techniques to manage aggressive behaviour. Attitudes towards management practices of seclusion, medication and restraint remained unchanged after RESPECT training. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Training programmes like RESPECT may be useful to improve attitudes towards causes of aggression and its management in LMIC hospitals. However, further evidence is required to demonstrate whether these results can be sustained over time and whether these attitudinal changes are associated with reduction of workplace violence. Mental health nurses and other mental health professionals can play a key role in establishing hospital-wide training and sharing skills across geographical boundaries. Abstract Introduction Occupational violence has been demonstrated to impact negatively on the well-being of nurses and patients. Staff attitudes towards causes and management of patients' aggression influence their practice. Training is likely to influence attitudes towards aggression; however, Uganda's health system lacks adequate resources to provide aggression management training for staff. Aim To assess the impact of a training programme (RESPECT) on staff attitudes towards causes and management of patient's aggression in a Ugandan hospital. Methods This study used a mixed-methods convergent design. A convenience sample of nurses and support staff employed in the psychiatric ward and other services across the hospital (N = 90) completed the Management of Aggression and Violence Attitude Scale (MAVAS) pre- and post-training. The views of a smaller sample (n = 35) were captured via interviews and focus groups and analysed using thematic analysis. Results Participants reported greater agreement with patients' physical and social environment (external and situational causative models) as factors influencing patient's aggression. Qualitative findings substantiated the results identified in the survey. Attitudes towards seclusion, restraint and medication remained unchanged. Discussion and implications for practice RESPECT has the potential to change staff attitudes towards aggression in the short term. Further research is needed to investigate long-term effects and impact on incidents of aggression.

Aggression in Acute Inpatient Psychiatric Care: A Survey of Staff Attitudes

Introduction

Inpatient aggression poses consistent complications for psychiatric hospitals. It can affect patient and staff safety, morale, and quality of care. Research on staff attitudes toward patient aggression is sparse.

Purpose

The study explored staff attitudes toward patient aggression by hospital position types and years of experience in a psychiatric hospital. We predicted that staff experiencing patient aggression would be related to working in less trained positions, having less psychiatric work experience, and demonstrating attitudes that were consistent with attributes internal to the patient and not external.

Methods

Fifty-one percent completed online survey using Management of Aggression and Violence Attitude Scale, along with demographics, years of work experience, and number of times staff experienced aggressive event.

Results

Management of Aggression and Violence Attitude Scale scores, staff position types, and years of experience were related to the number of aggressive interactions. Nurses and psychiatric technicians reported highest number of exposures to patient aggression, followed by physicians; however, support staff reported less patient aggression. More years worked in a psychiatric hospital was associated with more aggressive experience.

Conclusion

Nurses, psychiatric technicians, and physicians reported greater exposure to patients’ aggression than support staff. Training programs, developed specifically to individual position types, focusing on recognition of sources of aggression, integrated into staff training, might reduce patient on staff aggression in psychiatric hospitals.

Narrative Case Notes Have the Potential to Predict Seclusion 3 Days in Advance: A Mixed-Method Analysis

Objectives: Current risk assessment tools can predict problematic behavior and the need for coercive measures, but only with a moderate level of accuracy. The aim of this study was to assess antecedents and triggers of seclusion. Methods: Narrative notes of health care professionals on psychiatric inpatients were analyzed daily starting 3 days prior to seclusion in the case group (n = 26) and compared to a matched control group without seclusion (n = 26) by use of quantitative and qualitative research methods, based on qualitative content analysis. Results: Quantitative measures showed more aggression in the case group with highly significant differences between the groups (p < 0.001) at all measurement times. Seclusion was significantly associated with the total word count of the narrative notes. Subjective emotional expressions by staff were more apparent before seclusion (p = 0.003). Most frequently, subjective expressions regarding "arduous/provocative" (p < 0.001) and "anxious" (p = 0.010) sentiments could be identified in the case group. Description of patients' behavior in the case group included more negatively assessed terms (p = 0.001). Moreover, sleep loss, refusing medication, high contact frequency, demanding behavior and denied requests were present in a significantly higher frequency before seclusion. Expressions like "threatening" (p = 0.001) were found only before seclusion and appeared to have the function of personal risk assessment. The expression "manageable" (p = 0.035) appeared often in difficult situations that could still be handled. Conclusion: Several factors preceding seclusion could be identified. Narrative notes of staff already showed differences 3 days before the escalation. Particularly the word count, the analysis of terms describing patients' behavior, subjective expressions of staff, and terms used as a function of personal risk assessment could help to provide better predictions of aggressive incidents and to prevent coercive measures.

[Patient safety in psychiatric hospitalization - What incidents are reported and managed?]

INTRODUCTION

Reporting and management systems monitoring patient safety incidents (PSIs) facilitate the understanding of mechanisms of action and allow work on improvement activities to minimise their occurrence. In our country, little is known about the adverse effects of healthcare during psychiatric hospitalisation (PH). The aim of this study is to determine the occurrence and characteristics of the PSIs, as well as the improvement actions resulting from them, in the PH services being offered at the Parc Sanitari Sant Joan de Deu (an institution specialized in mental healthcare).

MATERIAL AND METHOD

An observational, descriptive, and cross-sectional study was conducted, covering the period 2013-2016. Analysis was made of the PSIs reported in the following areas of PH: acute and sub-acute (ASA), and medium and long-term stay (MLS). The following variables were identified: number, type and level of harm resulting from the PSIs, professional category of the person declaring the PSI, method of analysis used to investigate the PSI, and improvement actions generated by those PSIs that required either root-cause analysis or audit reports. The chi-squared test was used for statistical purposes when comparing percentages.

RESULTS

A total of 2,940 PSIs were reported. The frequency in ASA was significantly higher (7.1 per 1,000 stays) than in MLS (5.3). Almost all (97.6%) of the incidents were related to falls, aggressive and/or disturbed behaviour, mind-altering drugs, self-harm, medication, dangerous objects, and patients escaping. PSIs recording moderate or severe harm were similar in the 2 different areas (16.5% in ASA vs. 14.2% in MLS). A small percentage (1.02%) of the PSIs resulted in root cause analysis or audit reporting, due to their severity, and from those incidents, 56 improvement actions were generated.

CONCLUSIONS

PH demonstrates its own characteristics with regard to the type of PSIs and differs from general hospitalisation. Reporting of PSIs is higher in ASA than in MLS, although the level of harm experienced by the patients is similar. There is a clear understanding of reporting in PH, demonstrated by the steady increase in the numbers declared and also highlights the high level of awareness of the nursing staff.

Psychiatric Nurses' Attitudes Towards Violent Behaviour: A Brazilian Study

This study examines nurses' attitudes towards violent behaviour and the management of aggressiveness. A convenience sample of 185 nurses working in psychiatric urgent care and emergency services in Brazil responded to the MAVAS-BR. The results show that nurses' attitudes are more reflective of the external and situational models of violent behaviour and the use of control methods to manage aggressiveness. The mapping of this phenomenon using the same tools in a different context from those traditionally studied while observing similar results suggests a pattern of attitudes towards violent behaviour and the management of aggressiveness among nurses around the world.

A Scale for the Management of Aggressive and Violent Behaviour (C_MAVAS): Psychometric Properties Testing in Mental Health Nurses

Background: This study set out to examine the psychometric properties of C_MAVAS, a newly Chinese-translated version of MAVAS, a 27-item scale assessing healthcare professionals' attitudes to the management of patient violence. Method: The English version of the MAVAS was translated and back-translated to come up with C_MAVAS. A convenience sample of 262 qualified mental health nurses working in a local psychiatric hospital was recruited. Exploratory factor analysis tested C_MAVAS's construct validity. Results: Content validity of the C_MAVAS was very satisfactory with validity indices of 97.4% for the overall scale and 90% to 100% for individual items. Exploratory factor analysis yielded a four-factor solution: 'interactional perspectives on patient violence', 'best ways perceived for violence management', 'internal or biomedical perspectives on patient violence', and 'external perspectives on patient aggression and violence', were important in shaping their attitudes towards managing violence and patient disruptiveness. Internal consistency of the Chinese version was barely satisfactory (Cronbach's alpha = 0.51⁻0.67) for the four factors/subscales and its test-retest reliability was good (Pearson's coefficient = 0.84). Conclusion: The findings suggest the C_MAVAS is a valid and reliable tool to measure mental health nurses' attitudes towards patient violence/aggression in a mental hospital setting.

Deriving a Framework for a Systems Approach to Agitated Patient Care in the Emergency Department

BACKGROUND

The rising agitated patient population presenting to the emergency department (ED) has caused increasing safety threats for health care workers and patients. Development of evidence-based strategies has been limited by the lack of a structured framework to examine agitated patient care in the ED. In this study, a systems approach from the patient safety literature was used to derive a comprehensive theoretical framework for addressing ED patient agitation.

METHODS

A mixed-methods approach was used with ED staff members at an academic site and a community site of a regional health care network. Participants consisted of resident and attending physicians, physician assistants/nurse practitioners, nurses, technicians, and security officers. After a simulated agitated patient encounter to prime participants, uniprofessional and interprofessional focus groups were conducted, followed by a structured thematic analysis using a grounded theory approach. Quantitative data consisted of surveys of violence exposure and attitudes toward patient aggression and management.

RESULTS

Data saturation was reached with 57 participants. Violence exposure was higher for technicians, nurses, and officers. Conflicting priorities and management challenges occurred due to four main interconnected elements: perceived complex patient motivations; a patient care paradox between professional duty and personal safety; discordant interprofessional dynamics mitigated by respect and trust; and logistical challenges impeding care delivery and long-term outcomes.

CONCLUSION

Using a systems approach, five interconnected levels of ED agitated patient care delivery were identified: patient, staff, team, ED microsystem, and health care macrosystem. These care dimensions were synthesized to form a novel patient safety-based framework that can help guide future research, practice, and policy.

Aggression and violence in healthcare and its impact on nursing students: A narrative review of the literature

Aggression and violence is a significant social problem in many countries and an increasing problem in healthcare settings in which nurses are particularly vulnerable. The literature suggests that aggression and violence has a significant negative impact upon nurses and potentially upon nursing students and can result in these staff members experiencing stress as a direct result of these adverse events. The literature suggests that there is confusion over what constitutes aggression and violence in the workplace and therefore a true lack of understanding of the scale of the problem relating to nursing students. This review proposes that nursing students are indeed at significant risk of aggression and violence in the clinical setting which has the potential to significantly impact their role as a novice carer. Furthermore, aggression and violence can manifest negative stress responses in individuals, therefore, the potential for nursing students to cope with stressful situations shall be presented.

Effects of a Staff Training Intervention on Seclusion Rates on an Adult Inpatient Psychiatric Unit

The current article presents the effects of a 90-minute staff training intervention aimed at reducing inpatient psychiatric seclusion rates through strengthened staff commitment to seclusion alternatives and improved de-escalation skills. The intervention occurred at an 18-bed adult inpatient psychiatric unit whose seclusion rates in 2015 were seven times the national average. Although the project's primary outcome compared patient seclusion rates before and after the intervention, anonymous staff surveys measured several secondary outcomes. Seclusion rates were reduced from a 6-month pre-intervention average of 2.95 seclusion hours per 1,000 patient hours to a 6-month post-intervention average of 0.29 seclusion hours per 1,000 patient hours, a 90.2% reduction. Completed staff surveys showed significant staff knowledge gains, non-significant changes in staff attitudes about seclusion, non-significant changes in staff de-escalation skill confidence, and use of the new resource sheet by only 17% of staff. The key study implication is that time-limited, focused staff training interventions can have a measurable impact on reducing inpatient seclusion rates. [Journal of Psychosocial Nursing and Mental Health Services, 56(6), 23-30.].

Incidence, Type, Related Factors, and Effect of Workplace Violence on Mental Health Nurses: A Cross-sectional Survey

OBJECTIVE

Workplace violence and its impact on mental health nurses have yet to be thoroughly explored in China. This study aims to investigate the incidence, type, related factors, and effects of workplace violence on mental health nurses as well as identifying coping strategies.

METHODS

A researcher - designed workplace violence questionnaire and the Maslach Burnout Inventory-General Survey were distributed to nurses at a mental health hospital in Wuhan, China.

RESULTS

Most nurses reported a high incidence of workplace violence (94.6%) in the past year ranging from verbal aggression, sexual harassment, to physical attack. The forms of violence significantly correlated with each other (r>0.5, p=0.000). Working on the psychiatric intensive care unit for adult males and being a male nurse placed nurses at significantly higher risk for workplace violence. Providing routine treatment, caring for male patients, and working the night shift increased the risk of sexual harassment. Nurses who believed that workplace violence was preventable experienced a significantly lower incidence of violence. Burnout levels of the mental health nurses were relatively mild, but increased with age, professional title, years of employment and frequency of workplace violence.

CONCLUSION

The incidence of workplace violence among mental health nurses is common, and its frequency is correlated with nurses' level of burnout. Management and clinical nurses should work together on an organization-wide strategy targeting the major identified risk areas to reduce the incidence of workplace violence and minimize its impact on nurses.

Predicting aggressive behaviour in acute forensic mental health units: A re-examination of the dynamic appraisal of situational aggression's predictive validity

In the present study, we explored the predictive validity of the Dynamic Appraisal of Situational Aggression (DASA) assessment tool in male (n = 30) and female (n = 30) patients admitted to the acute units of a forensic mental health hospital. We also tested the psychometric properties of the original DASA bands and novel risk bands. The first 60 days of each patient's file was reviewed to identify daily DASA scores and subsequent risk-related nursing interventions and aggressive behaviour within the following 24 hours. Risk assessments, followed by documented nursing interventions, were removed to preserve the integrity of the risk-assessment analysis. Receiver-operator characteristics were used to test the predictive accuracy of the DASA, and generalized estimating equations (GEE) were used to account for repeated risk assessments, which occurs when analysing short-term risk-assessment data. The results revealed modest predictive validity for males and females. GEE analyses suggested the need to adjust the DASA risk bands to the following (with associated odds ratios (OR) for aggressive behaviour): 0 = low risk; 1, 2, 3 = moderate-risk OR, 4.70 (95% confidence interval (CI): 2.84-7.80); and 4, 5, 6, 7 = high-risk OR, 16.13 (95% CI: 9.71-26.78). The adjusted DASA risk bands could assist nurses by prompting violence-prevention interventions when the level of risk is elevated.

Need for Specialized Support Services for Nurse Victims of Physical Assault by Psychiatric Patients

Assault of nurses in the psychiatric setting is an ongoing global concern. In a prior study by these authors, many nurses reported concern about the lack of supportive interventions offered to nurses after the assault event. These nurses reported ongoing psychosocial and emotional disturbance consistent with symptoms of post-traumatic stress disorder. A follow-up study was done to investigate the perceived need of assaulted nurses for specialized support groups to assist them in dealing with the experience. A quantitative, cross sectional survey descriptive research design was done to assess assaulted nurses' perceived need for specialized support groups. The survey also gathered data relating to the reporting of the assault. A qualitative narrative section was added to gather data that might have been missed in the quantitative segment. The sample consisted of 57 previously assaulted nurses currently working at multiple acute care sites. Study findings showed that if specialized support groups were available, 57% of the nurses might be interested in attending these, and 41% would be interested in attending these. These nurses also reported multiple signs and symptoms of post-traumatic stress disorder. Considering the serious negative impact of assault on nurses and their desire for follow-up support, there is a need for the availability of supportive services.

Mental Health Nurses' Attitudes and Perceived Self-Efficacy Toward Inpatient Aggression: A Cross-Sectional Study of Associations With Nurse-Related Characteristics

PURPOSE

To explore mental health nurses' attitude and self-efficacy to adult inpatient aggression, and to explore the association with nurse-related characteristics.

DESIGN AND METHOD

Cross-sectional study in a sample of 219 mental health nurses in nine psychiatric hospitals, with stepwise linear regression analysis to detect predictive models.

FINDINGS

Female and less experienced nurses were less likely to blame patients for their behavior. Gender, burnout, secondary traumatic stress, and compassion satisfaction accounted for 26.2% of the variability in mental health nurses' self-efficacy toward aggression.

PRACTICE IMPLICATIONS

There needs to be attention to professional quality of life for mental health nurses, to provide them with of self-efficacy and a positive attitude toward coping with aggression.

Coordinating a Team Response to Behavioral Emergencies in the Emergency Department: A Simulation-Enhanced Interprofessional Curriculum

Introduction

While treating potentially violent patients in the emergency department (ED), both patients and staff may be subject to unintentional injury. Emergency healthcare providers are at the greatest risk of experiencing physical and verbal assault from patients. Preliminary studies have shown that a team-based approach with targeted staff training has significant positive outcomes in mitigating violence in healthcare settings. Staff attitudes toward patient aggression have also been linked to workplace safety, but current literature suggests that providers experience fear and anxiety while caring for potentially violent patients. The objectives of the study were (1) to develop an interprofessional curriculum focusing on improving teamwork and staff attitudes toward patient violence using simulation-enhanced education for ED staff, and (2) to assess attitudes towards patient aggression both at pre- and post-curriculum implementation stages using a survey-based study design.

Methods

Formal roles and responsibilities for each member of the care team, including positioning during restraint placement, were predefined in conjunction with ED leadership. Emergency medicine residents, nurses and hospital police officers were assigned to interprofessional teams. The curriculum started with an introductory lecture discussing de-escalation techniques and restraint placement as well as core tenets of interprofessional collaboration. Next, we conducted two simulation scenarios using standardized participants (SPs) and structured debriefing. The study consisted of a survey-based design comparing pre- and post-intervention responses via a paired Student t-test to assess changes in staff attitudes. We used the validated Management of Aggression and Violence Attitude Scale (MAVAS) consisting of 30 Likert-scale questions grouped into four themed constructs.

Results

One hundred sixty-two ED staff members completed the course with >95% staff participation, generating a total of 106 paired surveys. Constructs for internal/biomedical factors, external/staff factors and situational/interactional perspectives on patient aggression significantly improved (p<0.0001, p<0.002, p<0.0001 respectively). Staff attitudes toward management of patient aggression did not significantly change (p=0.542). Multiple quality improvement initiatives were successfully implemented, including the creation of an interprofessional crisis management alert and response protocol. Staff members described appreciation for our simulation-based curriculum and welcomed the interaction with SPs during their training.

Conclusion

A structured simulation-enhanced interprofessional intervention was successful in improving multiple facets of ED staff attitudes toward behavioral emergency care.

A qualitative investigation into nurses' perceptions of factors influencing staff injuries sustained during physical interventions employed in response to service user violence within one secure learning disability service

AIMS AND OBJECTIVES

The aim of the study was to examine learning disability nurses' perceptions of incidents involving physical intervention, particularly factors contributing to injuries sustained by this group.

BACKGROUND

This article reports on a qualitative study undertaken within one secure NHS Trust to respond to concerns about staff injuries sustained during physical interventions to prevent incidents of service user violence from escalating out of control. The context of the study relates to increasing debate about the most effective approaches to incidents of violence and agression.

DESIGN

A qualitative research design was utilized for the study.

METHODS

Semi-structured interviews were undertaken with 20 participants, two from each of the 10 incidents involving staff injury sustained during physical intervention.

RESULTS

Four themes were produced by the analysis, the first, knowledge and understanding, contextualized the other three, which related to the physical intervention techniques employed, the interpretation of the incident and the impact on staff.

CONCLUSION

Service user violence consistently poses nurses with the challenge of balancing the need to respond in order to maintain the safety of everyone whilst simultaneous supporting and caring for people with complex needs. This study highlights the need for further exploration of the contributory factors to the escalation of potentially violent situations.

RELEVANCE TO CLINICAL PRACTICE

Services may have good systems in place for responding to and managing service user violence but appear less effective in understanding the reasons for and developing strategies to prevent violence occurring.

Factors influencing clinicians' attitudes about aggression in Australian acute old age psychiatry inpatient units: a cross sectional survey design

Patient aggression occurs in old age psychiatry and is problematic. The aim of this study is to identify the factors that influence clinicians' attitudes toward aggression in old age psychiatry. Eighty-five individuals, comprising nurses (n = 75) and medical and allied health staff (n = 10), completed the questionnaire. The results show that gender, profession, and work experience do not affect attitudes toward aggression. A low score indicated agreement with an attitudinal statement. However, younger age, better higher level of completed education, and place of work increased the likelihood of participants endorsing the questionnaire's attitudinal statements about aggression. The findings suggest clinicians' attitudes may affect the way they attempt to prevent and manage aggression.

Attitudes of clinical staff toward the causes and management of aggression in acute old age psychiatry inpatient units

BACKGROUND

In psychiatry, most of the focus on patient aggression has been in adolescent and adult inpatient settings. This behaviour is also common in elderly people with mental illness, but little research has been conducted into this problem in old age psychiatry settings. The attitudes of clinical staff toward aggression may affect the way they manage this behaviour. The purpose of this study was to examine the attitudes of clinical staff toward the causes and management of aggression in acute old age psychiatry inpatient settings.

METHODS

A convenience sample of clinical staff were recruited from three locked acute old age psychiatry inpatient units in Melbourne, Australia. They completed the Management of Aggression and Violence Scale, which assessed the causes and managment of aggression in psychiatric settings.

RESULTS

Eighty-five staff completed the questionnaire, comprising registered nurses (61.1%, n = 52), enrolled nurses (27.1%, n = 23) and medical and allied health staff (11.8%, n = 10). A range of causative factors contributed to aggression. The respondents had a tendency to disagree that factors directly related to the patient contributed to this behaviour. They agreed patients were aggressive because of the environment they were in, other people contributed to them becoming aggressive, and patients from certain cultural groups were prone to these behaviours. However, there were mixed views about whether patient aggression could be prevented, and this type of behaviour took place because staff did not listen to patients. There was agreement medication was a valuable approach for the management of aggression, negotiation could be used more effectively in such challenging behaviour, and seclusion and physical restraint were sometimes used more than necessary. However, there was disagreement about whether the practice of secluding patients should be discontinued.

CONCLUSIONS

Aggression in acute old age psychiatry inpatient units occurs occasionally and is problematic. A range of causative factors contribute to the onset of this behaviour. Attitudes toward the management of aggression are complex and somewhat contradictory and can affect the way staff manage this behaviour; therefore, wide-ranging initiatives are needed to prevent and deal with this type of challenging behaviour.

Causes and management of aggression and violence in a forensic mental health service: perspectives of nurses and patients

Nurses' attitudes about the causes and management of aggression affects their choice of intervention. We aimed to compare the attitudes held by patients and staff in a forensic mental health service with the Management of Aggression and Violence Attitudes Scale, and examine the factor validity of the tool in this setting by conducting a prospective comparative questionnaire survey. Staff (n = 72) and patient (n = 98) attitudes differed to a limited extent. Confirmatory factor analysis refuted the previously reported structure of the tool. Exploratory factor analysis suggested three underlying factors related to modifiability of aggression, hands on management, and hands off management. Patients were more optimistic than nurses about the modifiability of aggressive behaviour. Male patients and those with diagnoses other than personality disorder were significantly more likely to agree about modifiability than controls. Forensic inpatients recognize the need for the use of a range of techniques to prevent and manage aggression and violence, but selected groups are most likely to believe that aggression is modifiable. Prevention and management of aggression training should emphasize the modifiability of aggressive behaviour. The development of measures of modifiability and management style would assist in the evaluation of training and would offer new avenues for research.

Kennedy Axis V: Clinimetric properties assessed by mental health nurses

The Kennedy Axis V is a routine outcome measurement instrument which can assist the assessment of the short-term risk for violence and other adverse patient outcomes. The purpose of this study was to evaluate the interrater reliability and clinical utility of the instrument when used by mental health nurses in daily care of patients with mental illness. This cross-sectional study was conducted in inpatient and outpatient adult psychiatric care units and in one adolescent inpatient unit at a university hospital in the Netherlands. Interrater reliability was measured based on the independent scores of two different nurses for the same patients. The clinical utility of the instrument was evaluated by means of a clinical utility questionnaire. To gain a deeper understanding of rating difficulties at the adolescent unit, additional data were collected in two focus group interviews. The overall results revealed a substantial level of agreement between nurses (intraclass correlation coefficient and Pearson 0.79). Some rating challenges were identified, including difficulties with scoring the instrument and using tailor-made interventions related to the scores. These challenges can be resolved using refined training and implementation strategies. When the Kennedy Axis V is accompanied by a solid implementation strategy in adult mental health care, the instrument can be used for short-term risk assessment and thereby contribute in efforts to reduce violence, suicide, self-harm, severe self-neglect, and enhanced objectivity in clinical decision-making.

Aggression in a high secure hospital: staff and patient attitudes

Responding to aggressive behaviour is a key activity for nurses and other care staff in high secure hospitals. The attitudes and beliefs of staff regarding patient aggression will influence the management strategies they adopt. Patients will also hold attitudes regarding the causes of and best ways to respond to aggressive behaviour. This study measured the attitudes towards aggression of staff (n= 109) and patients (n= 27) in a high secure hospital in the UK using the Management of Aggression and Violence Attitude Scale (MAVAS). There was considerable concordance of views, staff and patients disagreeing on only two items on the MAVAS. Aggression was felt to have a range of causes, embracing factors internal to the person, factors in the external environment and situational or interactional factors. Interpersonal means of managing aggression were supported, but both staff and patients also advocated the use of controlling management strategies such as medication, seclusion and restraint. The implications of these findings for aggression management in high secure settings are discussed in the light of best practice guidelines that promote interpersonal approaches over controlling strategies.

Frequency of assault and severity of injury of psychiatric nurses in relation to the nurses' decision to restrain

Ethical standards and current law demand that acute care psychiatric patients be treated with respect, using the least restrictive interventions. Unfortunately, as restraint use has decreased, assault and injury of mental health care workers has increased. Violence against those working in acute care psychiatry is a serious global issue that needs further examination. This study provides current, in depth information about the nature, frequency and severity of assaults and injuries of psychiatric nurses. This study also examined assault and injury in relation to the nurse's decision to restrain. The findings of this study were compared with findings of an earlier study carried out by one of the authors (Moylan) prior to the institution of policies, which are more restrictive in the use of restraint. In a sample of 110 nurses from five institutions, 80% of the nurses were assaulted, 65% had been injured and 26% had been seriously injured. Injuries included fractures, eye injuries and permanent disability. The number and severity of injuries have increased significantly since the 1996 study. Nurses who had been injured decided to restrain later in the progression of aggression than those who had not been injured.

A survey of staff attitudes and responses to people with dementia who are aggressive in residential care settings

Aggression is reportedly common among older people with dementia in residential care. The attitudes of staff in care homes and strategies they use are under researched. Theoretical models that may be used to both understand and respond to such behaviour exist. They are the standard and person-centred paradigms. The aim of this study was to explore the views of nursing staff about aggressive behaviour in people with dementia and strategies used in practice. A survey of the attitudes of staff in six dementia care units using the Management of Aggression in People with Dementia Attitude Questionnaire was conducted including an audit of aggressive incidents using the Staff Observation Aggression Scale-Revised over a 3-month period. Staff expressed views reflective of a person-centred as opposed to standard paradigm. They viewed aggressive behaviour by people with dementia as deriving from the environment, situation or interactions with others. Participants strongly supported interpersonal means of responding to aggression, the moderate use of medication, and were largely opposed to physical restraint. Aggressive incidents were managed using less intrusive strategies such as distraction and de-escalation. Responses to aggressive behaviour, while pragmatic, were largely underpinned by a person-centred ethic as reflected in the attitudes expressed by staff.

A pilot study to test an intervention for dealing with verbal aggression

Verbal aggression has been defined as communication with an intention to harm an individual through words, tone or manner, regardless of whether harm occurs. It includes verbal threat to harm, ridicule, openly hostile remarks, unjust persistent criticism, shouting or yelling insults, as well as more covert actions such as spreading hurtful rumours (Cox, 1987; Farrell et al, 2006). Receiving verbal aggression from a patient has been closely associated with psychological distress which may negatively affect work performance. A verbal aggression work book was developed to help nursing staff to deal with verbal aggression from patients in clinical practice. This was piloted over a six-week period with 18 nurses working on one acute psychiatric inpatient ward. Findings revealed that the intervention had some promising effects. However, much more attention needs to be paid to changing attitudes towards verbal aggression.