The effect of a training course on mental health nurses' attitudes on the reasons of patient aggression and its management

Development and evaluation of a de-escalation training intervention in adult acute and forensic units: the EDITION systematic review and feasibility trial

Background

Containment (e.g. physical restraint and seclusion) is used frequently in mental health inpatient settings. Containment is associated with serious psychological and physical harms. De-escalation (psychosocial techniques to manage distress without containment) is recommended to manage aggression and other unsafe behaviours, for example self-harm. All National Health Service staff are trained in de-escalation but there is little to no evidence supporting training's effectiveness.

Objectives

Objectives were to: (1) qualitatively investigate de-escalation and identify barriers and facilitators to use across the range of adult acute and forensic mental health inpatient settings; (2) co-produce with relevant stakeholders an intervention to enhance de-escalation across these settings; (3) evaluate the intervention's preliminary effect on rates of conflict (e.g. violence, self-harm) and containment (e.g. seclusion and physical restraint) and understand barriers and facilitators to intervention effects.

Design

Intervention development informed by Experience-based Co-design and uncontrolled pre and post feasibility evaluation. Systematic reviews and qualitative interviews investigated contextual variation in use and effects of de-escalation. Synthesis of this evidence informed co-design of an intervention to enhance de-escalation. An uncontrolled feasibility trial of the intervention followed. Clinical outcome data were collected over 24 weeks including an 8-week pre-intervention phase, an 8-week embedding and an 8-week post-intervention phase.

Setting

Ten inpatient wards (including acute, psychiatric intensive care, low, medium and high secure forensic) in two United Kingdom mental health trusts.

Participants

In-patients, clinical staff, managers, carers/relatives and training staff in the target settings.

Interventions

Enhancing de-escalation techniques in adult acute and forensic units: Development and evaluation of an evidence-based training intervention (EDITION) interventions included de-escalation training, two novel models of reflective practice, post-incident debriefing and feedback on clinical practice, collaborative prescribing and ward rounds, practice changes around admission, shift handovers and the social and physical environment, and sensory modulation and support planning to reduce patient distress.

Main outcome measures

Outcomes measured related to feasibility (recruitment and retention, completion of outcome measures), training outcomes and clinical and safety outcomes. Conflict and containment rates were measured via the Patient-Staff Conflict Checklist. Clinical outcomes were measured using the Attitudes to Containment Measures Questionnaire, Attitudes to Personality Disorder Questionnaire, Violence Prevention Climate Scale, Capabilities, Opportunities, and Motivation Scale, Coercion Experience Scale and Perceived Expressed Emotion in Staff Scale.

Results

Completion rates of the proposed primary outcome were very good at 68% overall (excluding remote data collection), which increased to 76% (excluding remote data collection) in the post-intervention period. Secondary outcomes had high completion rates for both staff and patient respondents. Regression analyses indicated that reductions in conflict and containment were both predicted by study phase (pre, embedding, post intervention). There were no adverse events or serious adverse events related to the intervention.

Conclusions

Intervention and data-collection procedures were feasible, and there was a signal of an effect on the proposed primary outcome.

Limitations

Uncontrolled design and self-selecting sample.

Future work

Definitive trial determining intervention effects.

Trial registration

This trial is registered as ISRCTN12826685 (closed to recruitment).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/101/02) and is published in full in Health Technology Assessment; Vol. 28, No. 3. See the NIHR Funding and Awards website for further award information.

Context

Conflict (a term used to describe a range of potentially unsafe events including violence, self-harm, rule-breaking, medication refusal, illicit drug and alcohol use and absconding) in mental health settings causes serious physical and psychological harm. Containment interventions which are intended to minimise harm from violence (and other conflict behaviours) such as restraint, seclusion and rapid tranquilisation can result in serious injuries to patients and, occasionally, death. Involvement in physical restraint is the most common cause of serious physical injury to National Health Service mental health staff in the United Kingdom. Violence to staff results in substantial costs to the health service in sickness and litigation payments. Containment interventions are also expensive (e.g. physical restraint costs mental health services £6.1 million and enhanced observations £88 million per annum). Despite these harms, recent findings indicate containment interventions such as seclusion and physical restraint continue to be used frequently in mental health settings. Clinical trials have demonstrated that interventions can reduce containment without increasing violence and other conflict behaviours (e.g. verbal aggression, self-harm). Substantial cost-savings result from reducing containment use. De-escalation, as an intervention to manage aggression and potential violence without restrictive practices, is a core intervention. 'De-escalation' is a collective term for a range of psychosocial techniques designed to reduce distress and anger without the need to use 'containment' interventions (measures to prevent harm through restricting a person's ability to act independently, such as physical restraint and seclusion). Evidence indicates that de-escalation involves ensuring conditions for safe intervention and effective communication are established, clarifying and attempting to resolve the patient's concern, conveyance of respect and empathy and regulating unhelpful emotions such as anxiety and anger. Despite featuring prominently in clinical guidelines and training policy domestically and internationally and being a component of mandatory National Health Service training, there is no evidence-based model on which to base training. A systematic review of de-escalation training effectiveness and acceptability conducted in 2015 concluded: (1) no model of training has demonstrated effectiveness in a sufficiently rigorous evaluation, (2) the theoretical underpinning of evaluated models was often unclear and (3) there has been inadequate investigation of the characteristics of training likely to enhance acceptability and uptake. Despite all National Health Service staff being trained in de-escalation there have been no high-quality trials evaluating the effectiveness and cost-effectiveness of training. Feasibility studies are needed to establish whether it is possible to conduct a definitive trial that can determine the clinical, safety and cost-effectiveness of this intervention.

Staff training in physical interventions: a literature review

Background

Restrictive practices are used frequently by frontline staff in a variety of care contexts, including psychiatric hospitals, children's services, and support services for older adults and individuals with intellectual and developmental disabilities. Physical restraint has been associated with emotional harm, physical injury to staff and consumers, and has even resulted in death of individuals in care environments. Various interventions have been implemented within care settings with the intention of reducing instances of restraint. One of the most common interventions is staff training that includes some physical intervention skills to support staff to manage crisis situations. Despite physical intervention training being used widely in care services, there is little evidence to support the effectiveness and application of physical interventions. This review will examine the literature regarding outcomes of staff training in physical interventions across care sectors.

Method

A systematic search was conducted following PRISMA guidelines using Cochrane Database, Medline EBSCO, Medline OVID, PsychINFO, and the Web of Science. Main search keywords were staff training, physical intervention, physical restraint. The MMAT was utilised to provide an analytical framework for the included studies.

Results and discussion

Seventeen articles have been included in this literature review. The included studies take place in a range of care settings and comprise a wide range of outcomes and designs. The training programmes examined vary widely in their duration, course content, teaching methods, and extent to which physical skills are taught. Studies were of relatively poor quality. Many descriptions of training programmes did not clearly operationalise the knowledge and skills taught to staff. As such, it is difficult to compare course content across the studies. Few papers described physical interventions in sufficient detail. This review demonstrates that, although staff training is a 'first response' to managing health and safety in care settings, there is very little evidence to suggest that staff training in physical intervention skills leads to meaningful outcomes.

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.

Effectiveness of an Aggression Management Training Program in Japan: A Quasi-Experimental Study

This study evaluated the effects of the Comprehensive Violence Prevention and Protection Program (CVPPP) training for managing patient aggression in 95 participants who attended the FY 2019 program using a single-group pretest-posttest design. The comparison of findings before and 1 month after the training showed a significant improvement in staff anger (p < 0.01) and their negative (p < 0.01) and positive attitudes (p < 0.01) toward psychiatric inpatient aggression and confidence (p < 0.01). Staff with controlling and self-affirming traits provided more effective care and demonstrated a positive attitude toward inpatient aggression (p < 0.05).Supplemental data for this article is available online at https://doi.org/10.1080/01612840.2021.1999542 .

Enhancing person-centred care in inpatient mental health settings through supported person-side handover: a multi method study

BACKGROUND

: Many nursing contexts have introduced bedside handover, where the person in care participates in the transfer of clinical information, with benefits for person, carers, and clinicians. This type of handover has been implemented across a number of mental health settings, but there is limited evidence regarding implementation approaches or of practice change. This study reports the development and evaluation of a co-produced education and support package.

AIM

: To evaluate changes in nurses' practice regarding bedside (person-side) handover following implementation of a structured education and support package.

DESIGN

: Multi-method design incorporating nurse surveys and chart audit.

METHODS

: The survey and audit were conducted in 2019-2020 on two inpatient mental health units in a metropolitan health service immediately prior to, and 6 months after, implementation, with 70 survey responses and 52 files audited. Non-parametric tests assessed change, and text comments were reported.

RESULTS

: Significant improvements were observed in nurses' reports of confidence, the ability to maintain privacy, identified benefits for the person and in information transfer. In contrast, the chart audit identified no change in documentation of this practice.

CONCLUSIONS

: The implementation of a co-produced education and support package demonstrated positive practice change in engaging people receiving care in handover. This approach to handover provides increased opportunity for nurses to work in partnership with people receiving mental healthcare, facilitating collaborative person-centred care and shared decision making.

[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.

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.

Patient and visitor aggression in healthcare: A survey exploring organisational safety culture and team efficacy

AIMS

This study investigates nurse managers' perception of organisational safety culture and team efficacy in managing patient and visitor aggression , and determines the predictors of team efficacy.

BACKGROUND

Patient and visitor aggression is a serious hazard in healthcare. A positive organisational safety culture regarding patient and visitor aggression enhances the safety and staff efficacy in managing patient and visitor aggression.

METHODS

A cross-sectional online survey including nurse managers in psychiatric and general hospitals (n = 446) was conducted in Switzerland, Austria and Germany (November 2016-February 2017). Data were analysed descriptively and through binary logistic regression.

RESULTS

The key results are as follows: "Working in a mental health setting" was 3.5 times more likely, "consideration of the physical environment" was four times more likely and a "shared organisational attitude" was twice as likely to predict high team efficacy. In comparison to psychiatric hospitals, general hospital managers perceived organisational safety cultures to be less positive.

CONCLUSIONS

A positive organisational safety culture leads to the perception that teams are more effective at managing patient and visitor aggression.

IMPLICATIONS FOR NURSING MANAGEMENT

Consideration of the physical environment and a positive shared organisational attitude regarding patient and visitor aggression are crucial for high team efficacy. General hospitals could benefit from approaches utilized in psychiatry to enhance staff efficacy in managing patient and visitor aggression.

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.

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.

A quantitative systematic review of the effects of training interventions on enhancing the competence of nursing staff in managing challenging patient behaviour

AIMS

This systematic quantitative review identifies and summarizes the current knowledge and effects of training interventions for managing patients' challenging behaviour.

BACKGROUND

Challenging behaviour is an acknowledged worldwide healthcare problem and its management can have a huge impact on quality of care. Evidence-based training interventions that focus on managing challenging behaviour are needed, but few tools for the systematic evaluation of these interventions are currently offered.

DESIGN

A quantitative systematic review following the 2008 Centre for Reviews and Dissemination guidelines.

DATA SOURCES

CINAHL, Scopus, PsycInfo, PubMed and Cochrane were searched using the same terms for papers published in English from 2005-2015.

REVIEW METHODS

Studies were assessed for quality and risk of bias, according to the Cochrane Effective Practice and Organisation of Care Group criteria. A narrative summary was conducted.

RESULTS

We included 17 studies and evaluated 16 training interventions. Interventions were classified into four key themes: disengagements, communication, controlling behavioural symptoms and restrictive measures. Our review showed that interventions were more likely to decrease violent incident rates and increase staff confidence than change staff attitudes or increase knowledge. The elements of competence used to manage challenging behaviour were measured unilaterally. The evidence provided by studies was largely weak.

CONCLUSION

The variety of measurements used in the studies made comparing the effectiveness of the training interventions difficult. An individual's competence to manage challenging behaviour needs to be defined and a comprehensive scale for evaluating competence is also needed. Patient safety should be included in future evaluations.

Workplace Violence Toward Mental Healthcare Workers Employed in Psychiatric Wards

Background

Workplace violence (WPV) against healthcare workers (HCWs) employed in psychiatric inpatient wards is a serious occupational issue that involves both staff and patients; the consequences of WPV may include increased service costs and lower standards of care. The purpose of this review was to evaluate which topics have been focused on in the literature and which are new in approaching the concern of patient violence against HCWs employed in psychiatric inpatient wards, in the past 20 years.

Methods

We searched for publications in PubMed and Web of Science using selected keywords. Each article was reviewed and categorized into one or more of the following four categories based on its subject matter: risk assessment, risk management, occurrence rates, and physical/nonphysical consequences.

Results

Our search resulted in a total of 64 publications that matched our inclusion criteria. The topics discussed, in order of frequency (from highest to lowest), were as follows: “risk assessment,” “risk management,” “occurrence rates,” and “physical/nonphysical consequences.” Schizophrenia, young age, alcohol use, drug misuse, a history of violence, and hostile-dominant interpersonal styles were found to be the predictors of patients’ violence.

Conclusion

Risk assessment of violence by patients appeared the way to effectively minimize the occurrence of WPV and, consequently, to better protect mental HCWs. We found paucity of data regarding psychologic sequelae of WPV. According to these findings, we suggest the need to better investigate the psychologic consequences of WPV, with the aim of checking the effective interventions to assist HCW victims of violence and to prevent psychologic illness.

Assault experiences: Lessons learned from mental health nurses in Taiwan

Mental health nurse are frequently subjected to patients' violent and aggressive behaviour. These assault experiences have given rise to mental health nurses' physical and psychological trauma, and negatively impact the quality of patient care. The purpose of the present qualitative study was to understand mental health nurses' experiences of being assaulted, the influences on their patient care, and their perspectives of the effectiveness of in-service, violence-prevention education. Ten mental health nurses from two different inpatient mental health facilities were interviewed using a semistructured interview guide. Thematic analysis of interview data found six themes: (i) violence is unpredictable; (ii) violence is normal; (iii) lasting psychological trauma; (iv) limited support from peers and the administrator; (v) violence prevention requires team cooperation; and (vi) doubting the effectiveness of in-service education on violence prevention. Psychiatric ward administrators should assess nurses' learning and skill needs to determine whether these needs are met by existing in-service training programmes. A culture of safety should also be promoted by building a warm and supportive ward climate for both staff and patients, which would include team cooperation and support for colleagues who suffer a violent incident.

Patient Aggression in Real Time on Geriatric Inpatient Units

This study focused on verbal and physical aggression against nursing staff, in real time, by elderly patients. The aggressive incidents were recorded at the end of each shift when they were more likely to be accurately remembered. Before beginning the study, nursing staff were taught how to use the Modified Overt Aggression Scale (MOAS) to identify aggressive acts. High rates of verbal and physical aggression among the elderly were observed by nurses, and data show that 75% of nursing staff experienced aggression on their shift. They either experienced aggression themselves or observed aggression on every single shift; that is at least five violent incidents in a work-week. Even if one is not the target of aggression, such observation is associated with elevated levels of stress.

Seclusion and the importance of contextual factors: An innovation project revisited

Variation in seclusion rates between psychiatric facilities cannot be adequately explained by patient characteristics alone and there is a growing awareness of the influence of 'cultural' and staff factors on the use of seclusion. In this study, staff variables as well as seclusion parameters were investigated during the implementation of an innovation project, against the background of an institutional program to reduce the use of coercive measures. The results demonstrate the impact of confidence within the team, staffing level and communication with the patient on nurses' decisions on seclusion. The importance of the organizational context is further illustrated by the negative effects of organizational instability on nurses' attitudes and decision making with respect to seclusion, and on seclusion rates. A reduction in the use of seclusion was achieved after the implementation of the innovation project; however, during a period of organizational turmoil, the work engagement scores of staff decreased and the use of seclusion increased. The results of this study show the vulnerability of innovations within the continuously changing organizational context of mental health care.

Managing and caring for distressed and disturbed service users: the thoughts and feelings experienced by a sample of English mental health nurses

This paper reports the thoughts and feelings experienced by registered mental health nurses caring for distressed and/or disturbed service users in acute inpatient psychiatric settings in England. The prevailing thoughts of nurses were of cognitive dissonance and the conflict between benevolence and malevolence if coercive measures were seen as negative rather than positive; prevailing feelings experienced by nurses were fear, anxiety and vulnerability. To enhance care quality, nurses expressed the need for better communication with service users, and preventing the use of coercive measures and promotion of alternative methods of care and management. The nurses considered that debriefing dialogues following untoward incidents, practice development initiatives, education and training together with clinical supervision could be the way forward. The paper builds on the existing literature in offering clear explanations of nurses' thoughts and feelings when caring for distressed and/or disturbed service users in an English acute, inpatient psychiatric setting. Despite the small sample size and the limitations that it generates, the study findings will be of interest to the wider mental health nursing community. The findings will link to other national and international studies and therefore be valuable for future research studies of this kind. Collectively, they are building up a general picture of the distress, cognitive and emotional dissonance experienced by mental health nurses when using coercive interventions. The findings will help to develop mental health nurse education and enhance practice. High levels of distress and disturbance among service users experiencing acute mental illness is a major problem for mental health nurses (MHNs). The thoughts and feelings experienced by these nurses when caring for service users are of paramount importance as they influence clinical practice and caregiving. Similarly to research by other countries, this paper reports national, qualitative data regarding the thoughts and feelings of English MHNs who care for these service users within acute inpatient psychiatric settings. Data were collected from focus groups in which MHNs working in acute inpatient settings in England participated and analysed using inductive content analysis. Findings highlighted three broad themes: (1) emotional and cognitive dissonance; (2) therapeutic engagement; and (3) organizational management and support. The prevailing thoughts of nurses were of cognitive dissonance and the conflict between benevolence and malevolence if coercive measures were seen as negative rather than positive; the prevailing feelings experienced by nurses were fear, anxiety and vulnerability. Nurses would like better communication with service users, prevention of coercive measures and the use of alternative methods of care and/or management to ensure enhanced care. Participants considered practice development initiatives, education, training, staff and managerial support including debriefing and clinical supervision as the way forward. Despite the small sample size and its limitations, these national data add to the existing literature, and the study findings link to those of other studies both nationally and internationally. Collectively, these studies are building up a general picture of the distress, cognitive and emotional dissonance experienced by MHNs when using coercive interventions. The findings will help to develop MHN education and enhance practice.

Learning and performance outcomes of mental health staff training in de-escalation techniques for the management of violence and aggression

BACKGROUND

De-escalation techniques are a recommended non-physical intervention for the management of violence and aggression in mental health. Although taught as part of mandatory training for all National Health Service (NHS) mental health staff, there remains a lack of clarity around training effectiveness.

AIMS

To conduct a systematic review of the learning, performance and clinical safety outcomes of de-escalation techniques training.

METHOD

The review process involved a systematic literature search of 20 electronic databases, eligibility screening of results, data extraction, quality appraisal and data synthesis.

RESULTS

A total of 38 relevant studies were identified. The strongest impact of training appears to be on de-escalation-related knowledge, confidence to manage aggression and deescalation performance (although limited to artificial training scenarios). No strong conclusions could be drawn about the impact of training on assaults, injuries, containment and organisational outcomes owing to the low quality of evidence and conflicting results.

CONCLUSIONS

It is assumed that de-escalation techniques training will improve staff's ability to de-escalate violent and aggressive behaviour and improve safety in practice. There is currently limited evidence that this training has these effects.

[Psychiatry with open doors. Part 2: Therapeutic challenges]

In the previous part of the issue we argued that opening the doors of acute psychiatric inpatient wards is actually one of the anchor points on the way to an innovative psychiatry. It focuses on the patient's personality in a sense that this is taken as seriously as the psychiatric disorder itself. Patients and relatives should be enabled to participate in treatment decisions as they should experience that treatment teams are concerned about reliance, liability and security in therapeutic relationships in an empathetic way. The second part of the issue contributes to the therapeutic measures, the different skills and modifications of treatment frameworks in acute psychiatry (e.g. prevention of crowding in acute psychiatric inpatient units, education of staff, assessment of the risks of violence, de-escalation strategies and coping with suicidality). They might be helpful in implementing the outlined confidence about the essence of therapeutic relationships, autonomy and codetermination of patients in treatment. These suggestions might enhance a professional approach particularly with respect to prevention and also concerning acute interventions in situations of endangerment to self and others and of aggression and violence in the units. In this way they help to achieve the goal of open doors in psychiatry.

'Violence is not part of our job': a thematic analysis of psychiatric mental health nurses' experiences of patient assaults from a New Zealand perspective

This paper describes psychiatric mental health nurses' (PMHN) experiences of patient assaults within mental healthcare settings using a thematic analytical approach. The aim of the study was to explore and describe psychiatric mental health nurses' experiences of patient assaults. The major findings of the study related to the nature and impact of assaults and supportive strategies associated with violence perpetrated by patients against psychiatric mental health nurses. Perpetrator risk factors for patients include mental health disorders, alcohol and drug use and the inability to deal with situational crises. The injuries sustained by nurses in the context of the study include lacerations, head injuries, dislocations and bruises. Psychological harm has also occurred, including quite severe mental health problems, such as post-traumatic stress disorder. Protective strategies for combating negative consequences of workplace violence include practice of self-defence, social support and a supportive and consultative workplace culture with access to counselling services and assistance in all aspects, including finances. The paper concludes that while healthcare employers need to provide better support services to the healthcare professionals who are assaulted, the legal system also needs to acknowledge that assaults against nurses are a violation of human rights and violence should not to be tolerated as part of working in mental healthcare settings.

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.

At the crossroads of violence and aggression in the emergency department: perspectives of Australian emergency nurses

Objective Violence is widespread in Australian emergency departments (ED) and most prevalent at triage. The aim of the present study was to identify the causes and common acts of violence in the ED perceived by three distinct groups of nurses. Methods The Delphi technique is a method for consensus-building. In the present study a three-phase Delphi technique was used to identify and compare what nurse unit managers, triage and non-triage nurses believe is the prevalence and nature of violence and aggression in the ED. Results Long waiting times, drugs and alcohol all contributed to ED violence. Triage nurses also indicated that ED staff, including security staff and the triage nurses themselves, can contribute to violence. Improved communication at triage and support from management to follow up episodes of violence were suggested as strategies to reduce violence in the ED Conclusion There is no single solution for the management of ED violence. Needs and strategies vary because people in the waiting room have differing needs to those inside the ED. Participants agreed that the introduction and enforcement of a zero tolerance policy, including support from managers to follow up reports of violence, would reduce violence and improve safety for staff. Education of the public regarding ED processes, and the ED staff in relation to patient needs, may contribute to reducing ED violence. What is known about the topic? Violence is prevalent in Australian healthcare, and particularly in emergency departments (ED). Several organisations and government bodies have made recommendations aimed at reducing the prevalence of violence in healthcare but, to date, these have not been implemented consistently, and violence continues. What does this paper add? This study examined ED violence from the perspective of triage nurses, nurse unit managers and non-triage nurses, and revealed that violence is experienced differently by emergency nurses, depending on their area of work. Triage nurses have identified that they themselves contribute to violence in the ED by their style of communication. Nurse unit managers and non-triage nurses perceive that violence is the result of drugs and alcohol, as well as long waiting times. What are the implications for practitioners? Strategies to reduce violence must address the needs of patients and staff both within the ED and in the waiting room. Such strategies should be multifaceted and include education of ED consumers and staff, as well as support from management to respond to reports of violence.

The Diagnostic Efficiency of the Extended German Brøset Violence Checklist to Assess the Risk of Violence

Background and Purpose: The prevention of aggression and violence of patients is part of the challenge for the psychiatric inpatient care. Resources needed are a systematic risk assessment and taking preventive measures according to the risk. The extended Brøset Violence Checklist (BVC-CH) is an assessment instrument for the short-term assessment of the risk of violence for physical attacks toward medical staff and other patients. Until now, the instrument was only validated in the context of the development phase of the instrument. The aim of this study was to investigate how valid the BVC-CH scale is for adult psychiatry in acute inpatient care facilities. Methods: In a prospective cohort study, 232 consecutively admitted patients were assessed using the BVC-CH. The calculation of the predictive values was based on a contingency table. The discriminatory power of the instrument and the determination of the cutoff point were done using the receiver operating characteristic (ROC) curve analysis. Physical attacks were registered with the Staff Observation of Aggression Scale–Revised (SOAS-R). Results: The sensitivity was 58.8% and the specificity was 96.8% by a cutoff point of ≥7. By choosing a cutoff point of ≥6, the sensitivity was 64.7% and the specificity was 95.1%. A value of .93 was determined for the area under the curve receiver operating characteristic (AUCROC). Conclusions: Overall, the BVC-CH is a valid instrument for the short-term prediction of physical attacks. Further research of the BVC-CH is recommended but in particular for the cutoff point.

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.

Iranian nurses' experiences of aggression in psychiatric wards: a qualitative study

Aggression from psychiatric patients is a constant problem for care providers that causes major problems in the therapeutic environment, and may have negative effects on the quality of care. Since recognition of aggression with regard to cultural background leads to better control of aggression in the psychiatric wards, this study has been done to clarify Iranian nurses' experiences of aggression in psychiatric wards. A qualitative content analysis study was conducted to explore experiences of nurses. Data analysis revealed four themes: (1) Damage resulting from aggression, (2) Aggression catalysts, (3) Contagious nature of aggression, and (4) Various control strategies. There are various causes for in-patients' aggression, and nurses use various approaches to control it. These approaches are influenced by personnel, facilities, and ward environment. Identifying these factors and strategies can contribute to better management of aggression and, thus, better quality of care in psychiatric wards.

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.

The influence of staff training on the violence prevention and management climate in psychiatric inpatient units

Violence prevention and management is an important part of inpatient psychiatric nursing and specific staff training is regarded essential. The training should be based on primary, secondary and tertiary prevention. In Stockholm, Sweden, the Bergen model is a staff-training programme that combines this preventive approach with the theoretical nursing framework of the City model that includes three staff factors: positive appreciation of patients, emotional regulation and effective structure. We evaluated this combination of the Bergen and City models on the violence prevention and management climate in psychiatric inpatient wards. A 13-item questionnaire was developed and distributed to patients and staff in 41 wards before the staff was trained and subsequently to 19 of these wards after training. Data analyses included factor analysis, Fisher's exact test and Mann-Whitney U-test. The result showed that the staff on trained wards had a more positive perception of four of the items and the patients of one item. These items reflected causes of patient aggression, ward rules, the staff's emotional regulation and early interventions. The findings suggest that a focus on three levels of prevention within a theoretical nursing framework may promote a more positive violence prevention and management climate on wards.

The outcome of a rapid training program on nurses' attitudes regarding the prevention of aggression in emergency departments: a multi-site evaluation

BACKGROUND

Patient aggression is a common source of occupational violence in emergency departments. Staff attitudes regarding the causes for aggression influence the way they manage it. The Management of Clinical Aggression - Rapid Emergency Department Intervention is a 45 min educational program that aims to promote the use of de-escalation techniques and effective communication skills to prevent patient aggression.

OBJECTIVE

We sought to evaluate the impact of the program on staff attitudes regarding the prevention and early management of patient aggression.

DESIGN

A mixed methods approach was used including a pre-test post-test survey of training participants and individual interviews with key stakeholders.

SETTING AND SAMPLE

The setting was public sector hospital emergency departments located in metropolitan and regional Victoria, Australia. A convenience sample of eighteen emergency departments was recruited via the Victorian Department of Health.

PARTICIPANTS

Survey participants were nurses and midwives who were employed at the study sites. Interview participants were a purposive sample of nurse unit managers and trainers.

METHODS

The Management of Aggression and Violence Attitude Scale was administered to training participants immediately before and 6-8 weeks after training. Semi-structured telephone interviews with trainers and managers occurred 8-10 weeks after the intervention.

RESULTS

Four hundred and seventy one participants completed the pre-test and post-test. Statistically significant shifts were observed in 5/23 items (Wilcoxon Signed Ranks Test: p ≤ 0.01). Despite training, participants were undecided if it was possible to prevent patient aggression, and continued to be unsure about the use of physical restraint. Twenty-eight (82.3%) of managers' and trainers' eligible to be interviewed provided their perceptions of the impact of the program. Overall, these perceptions were consistent with the significant shifts observed in the survey items.

CONCLUSION

There was limited evidence to demonstrate that the program significantly modified staff attitudes towards the prevention of patient aggression using the Management of Aggression and Violence Attitude Scale. Additional survey items that specifically measure staff attitudes about the use of restraint in emergency settings are needed to better understand decision making about restraining practices. Further work is indicated to quantify the impact of training in practice.

Clinical risk management in mental health: a qualitative study of main risks and related organizational management practices

Background

A scientific understanding of clinical risk management (CRM) in mental health care is essential for building safer health systems and for improving patient safety. While evidence on patient safety and CRM in physical health care has increased, there is limited research on these issues in mental health care. This qualitative study provides an overview of the most important clinical risks in mental health and related organizational management practices.

Methods

We conducted in-depth expert interviews with professionals responsible for CRM in psychiatric hospitals. Interviews were transcribed and analyzed applying qualitative content analysis to thematically sort the identified risks.

Results

The main concerns for CRM in mental health are a) violence and self-destructive behavior (i.e. protecting patients and staff from other patients, and patients from themselves), b) treatment errors, especially in the process of therapy, and c) risks associated with mental illnesses (e.g. psychosis or depression). This study identified critical differences to CRM in hospitals for physical disorder and challenges specific to CRM in mental health. Firstly, many psychiatric patients do not believe that they are ill and are therefore in hospital against their will. Secondly, staff safety is a much more prominent theme for CRM in mental health care as it is directly related to the specifics of mental illnesses.

Conclusions

The current study contributes to the understanding of patient safety and raises awareness for CRM in mental health. The mental health specific overview of central risks and related organizational management practices offers a valuable basis for CRM development in mental health and an addition to CRM in general.

Breakaway technique training as a means of increasing confidence in managing aggression in neuroscience nursing

OBJECTIVE

The objective of this paper was to evaluate breakaway technique training with neuroscience nursing staff as a measure of increased confidence and safety in managing aggression.

METHODS

A quasi experimental design was used in a sample of neuroscience nursing staff (n=31), participating in 2×1h breakaway technique workshops. The workshops consisted of supervised skills training in safe breakaway techniques. A pre- and postintervention-matched questionnaire measuring confidence and safety around managing aggressive patients, and exposure to and confidence in dealing with breakaways, was self administered.

RESULTS

Statistically significant increases in confidence and safety in working with aggressive patients, and confidence levels for safe breakaways were reported. Qualitative comments demonstrated a desire for ongoing skills workshops.

CONCLUSIONS

This study provides early evidence of the importance of incorporating breakaway training into existing training programs which aim to minimise and manage aggression and violence in generalist settings.

Mechanical restraint--which interventions prevent episodes of mechanical restraint?- a systematic review

PURPOSE

To identify interventions preventing mechanical restraints.

DESIGN AND METHODS

Systematic review of international research papers dealing with mechanical restraint. The review combines qualitative and quantitative research in a new way, describing the quality of evidence and the effect of intervention.

FINDINGS

Implementation of cognitive milieu therapy, combined interventions, and patient-centered care were the three interventions most likely to reduce the number of mechanical restraints.

PRACTICE IMPLICATIONS

There is a lack of high-quality and effective intervention studies. This leaves patients and metal health professionals with uncertainty when choosing interventions in an attempt to prevent mechanical restraints.

Wounding words: swearing and verbal aggression in an inpatient setting

PURPOSE

The aim of the research was to investigate swearing and verbal aggression in Australian inpatient settings, including incidence, gender, patient motivation, and nursing interventions.

DESIGN AND METHODS

A mixed methods approach utilizing the Overt Aggression Scale and a survey of 107 nurses' perceptions of their experience of swearing was used.

FINDINGS

High levels of swearing and verbal aggression were found, with differing patterns for male and female patients. Nurses subjected to swearing experienced high levels of distress, especially females. All nurses appeared to use a limited range of interventions to deal with patient aggression.

PRACTICAL IMPLICATIONS

In order to provide optimal care for patients, there is a clear need to improve nurses' ability to predict and prevent aggression.

Officer attitudes towards intra-group aggression in young people and young adults: does the reported motivation of an aggressor impact on intervention and support?

The present study aims to assess whether global and context specific attitudes influence the ability to correctly identify the motivation for aggression and selection of appropriate intervention strategies. A sample of 105 prison officers completed a measure assessing global attitudes towards prisoners, one assessing context specific attitudes towards aggression, and also a case vignette. Officers were asked to consider the motivation for aggression and to select an appropriate intervention. It was predicted that sex, age and level of experience would impact on global and context specific attitudes. Officers expressing positive global attitudes and non-aggressive context specific attitudes were expected to be more able to identify the motivation for aggression and more likely to adopt a rehabilitative approach. There was evidence to indicate sex differences in global and context specific attitudes but no impact of age. Level of experience of aggression impacted both on global and context specific attitudes. Global or context specific attitudes did not influence the ability to interpret aggression, but aggression type did. Limitations and directions for future research are discussed.

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.

Violence and restraint reduction efforts on inpatient psychiatric units

Efforts to reduce aggression and violence and the use of restraint and seclusion have traditionally been through some form of educational program. This paper presents an integrative review of research and quality improvement projects that aimed to reduce aggression/violence or restraint/seclusion through the use of an educational program. Forty-six papers are included in this review. This paper presents summaries and comparisons of the research designs, the content and length of programs, and the outcomes of these programs. From these summaries, trends in relation to design, content, and outcomes are identified, and recommendations for clinicians and researchers are given.

A narrative review of the effectiveness of aggression management training programs for psychiatric hospital staff

Workplace violence, including patient-perpetrated violence in healthcare settings, is increasingly being recognized as preventable. Staff training has been identified as a necessary component of any initiative aimed at preventing or reducing incidents of aggression and violence in the workplace. This narrative review of the literature evaluates the effectiveness of staff training programs designed to prevent and manage violence and aggression in psychiatric hospitals. An exhaustive review of the literature was performed on all articles published in English between January 1, 1990 and April 1, 2007 that evaluate an aggression management training program. Twenty-nine studies met the inclusion criteria for a full review and were summarized using a qualitative narrative approach. Aggression management training has been proven effective in some areas, such as reducing the use of restraints and other coercive control devices, but more methodologically rigorous research is needed to firmly establish whether it is effective in reducing aggression and staff injuries.

IMPLICATIONS

The findings of this study suggest that relying too heavily on aggression management staff training will have limited effect on addressing the range of issues related to patient-perpetrated violence in psychiatric hospitals. Mental healthcare organizations must look beyond staff training if they are to achieve meaningful reductions in aggressive incidents and staff injuries.

A review of ecological factors affecting inpatient psychiatric unit violence: implications for relational and unit cultural improvements

This review examines the research on ecologic factors that may contribute to or lessen the likelihood of inpatient unit violence. Understanding these factors can provide psychiatric inpatient unit staff with valuable therapeutic relational and cultural strategies to decrease violence. International and US studies from OVID Medline, CINAHL, and PsycInfo that evaluated aggression and violence on psychiatric inpatient units between 1983 and 2008 were included in this review. The review revealed that violence results from the complex interactions among the patient, staff, and culture of the specific unit. Inpatient psychiatric staff can decrease the potential for violence by using therapeutic relationship strategies such as using good communication skills, advocating for clients, being available, having strong clinical assessment skills, providing patient education, and collaborating with patients in treatment planning. Cultural improvements include providing meaningful patient activities and appropriate levels of stimulation and unit staffing.

Relating new graduate nurse competence to frequency of use

The healthcare workplace can be a stress-laden environment for new graduates and job performance indicators are an important sign of developing confidence and expertise that will lead to improved patient outcomes. What is not evident from nursing studies is whether new graduate nurse competencies relate to the frequency of their use. This study sought to determine the relationship between perceived nursing competence and self-assessed frequency of use by new graduate nurses. Three cohorts (n = 116) of new graduate nurses undertaking year-long transition to graduate practice programs responded to a questionnaire that utilised the 2001 ANCI competencies and the Nurse Competency Scale and a Visual Analogue scale to self assess their perceived competence and the relative frequency of use for specific competence items. Results indicate that a relationship exists between perceived competence and frequency of use and that research competency scores are substantially lower than all other categories of competency. Implications for education and practice indicate that assessment of nurse competency for the new graduate nurse should focus on the development of generic nursing competencies rather than current expectation of advanced and workplace specific nurse competencies.