The nurse's role in the management of aggression

A Virtual, Simulated Code White for Undergraduate Nursing Students

Background

Nurses and nursing students are increasingly vulnerable to workplace violence, both verbal and physical, as health care settings and clients cope with unprecedented challenges including the COVID-19 pandemic. Concurrently, clinical learning opportunities for nursing students have been curtailed by public health restrictions and limited capacity. While virtual simulations have been promoted as an alternative to clinical hours, their effectiveness as an educational intervention on workplace violence has yet to be assessed.

Purpose

The authors sought to evaluate a virtual, simulated code white—a set of organized responses to a client, visitor, or staff member exhibiting the potential for violence—involving 4th year undergraduate nursing students, randomly sorted into an intervention group and a control group.

Methods

Pre and post test measures of knowledge and attitudes about mental health, workplace violence and virtual simulation were collected, as well as qualitative data from focus groups.

Findings

While the sample size (n = 24) was insufficient to detect meaningful differences between the intervention and control groups, descriptive statistics and focus group data revealed significant gaps in participants’ knowledge around managing workplace violence. Participants rated the virtual simulation highly for its realism and the opportunity to experience working in a virtual environment, while they felt the preamble and debrief were too short.

Conclusions

The findings illustrate a virtual code white simulation has clear educational benefits, and that multiple iterations, both virtual and in person, would most likely increase the benefits of the intervention.

Whose fault is it? Attribution of causes of patient violence among exposed and unexposed community-based family physicians

Extensive research has dealt with violence directed at healthcare workers in hospital settings; however, few studies have examined community-based settings. Furthermore, there is also scant literature regarding the perceptions of healthcare providers who were exposed to violence, compared to those who were not. This study aims to narrow these gaps in the literature by examining community-based family physicians' (CBFPs) perceptions in a large national Health Maintenance Organisation (HMO) regarding patient-initiated violence. Using a voluntary online survey, directed at all CBFPs working at the HMO, 412 CBFPs were surveyed on the following issues: exposure to violence initiated by patients or their family members; perceptions of violent occurrences and possible safety measures. The differences between CBFPs who had been exposed to violence and those who had not were compared. The majority of CBFPs reported experiencing verbal attacks (64%), and a small percentage experienced property-related violence (11.7%) or physical violence (3.4%). Comparing CBFPs who were exposed to violence with those who were not, regarding their perceptions of the 'causes of violence', revealed three differentiating factors: 'waiting time', 'failure to meet the patient's expectations' and 'the nature of the physician-patient encounter'. Regarding the desired preventive actions, the four differentiating factors were as follows: 'reduction in the number of patients per physician', 'improved queue management processes', 'longer meetings' and 'violence prevention training'. Conducting separate analyses, according to violence type (verbal abuse, vandalism or physical violence), indicated finer differentiations. In terms of Attribution Theory, one might argue that CBFPs who were directly exposed to patients' aggression attributed internal locus to the attacker, and tended to blame the attacker's personal characteristics and cultural values. Conversely, family CBFPs who were not attacked attributed external locus to situational factors such as waiting time, not receiving service, and the nature of the interaction between the attacker and the CBFP.

Providing Health Care in the Shadow of Violence: Does Emotion Regulation Vary Among Hospital Workers From Different Professions?

Research into violence against health care staff by patients and their families within the health care services shows a rising frequency of incidents. The potentially damaging effects on health care staff are extensive, including diverse negative psychological and physical symptoms. The aim of this qualitative study was to examine how hospital workers from different professions reacted to patients' and visitors' violence against them or their colleagues, and how they regulated their emotional reactions during those incidents. The research question was as follows: How do different types of hospital workers regulate the range of their emotional reactions during and after violent events? Participants were 34 hospital workers, representing several professional sectors. Data were collected through in-depth semistructured interviews, which were later transcribed and thematically content analyzed. Five themes were revealed, demonstrating several tactics that hospital workers used to regulate their emotions during incidents of violent outbursts by patients or visitors: (1) Inability to Manage Emotion Regulation, (2) Emotion Regulation by Distancing and Disengagement Tactics, (3) Emotion Regulation Using Rationalization and Splitting Tactics, (4) Emotion Regulation via the Use of Organizational Resources, and (5) Controlling Emotions by Suppression. Hospital workers who experienced dissonance between their professional expectations and their emotional reactions to patients' violence reported using various emotion regulation tactics, consequently managing to fulfill their duty competently. Workers who did not experience such dissonance felt in full control of their emotions and did not manifest responses of emotion regulation. Others, however, experienced intense emotional flooding and failed to regulate their emotions. We recommend developing health care staff's awareness of possible emotional implications of violent incidents, for themselves as people and for their intact functioning at work. In addition, we recommend further development of health care staff training programs for coping with violent patients and enhancement of formal and informal organizational support.

Violence and aggression in psychiatric inpatient care in Sweden: a critical incident technique analysis of staff descriptions

BACKGROUND

Violence towards staff working in psychiatric inpatient care is a serious problem. The aim of the present study was to explore staff perspectives of serious violent incidents involving psychiatric inpatients through the following research questions: Which factors contributed to violent incidents, according to staff? How do staff describe their actions and experiences during and after violent incidents?

METHODS

We collected data via a questionnaire with open-ended questions, and captured 283 incidents reported by 181 staff members from 10 inpatient psychiatric wards in four different regions. We used the Critical Incident Technique to analyse the material. Our structural analysis started by structuring extracts from the critical incidents into descriptions, which were grouped into three chronological units of analyses: before the incident, during the incident and after the incident. Thereafter, we categorised all descriptions into subcategories, categories and main areas.

RESULTS

Staff members often attributed aggression and violence to internal patient factors rather than situational/relational or organisational factors. The descriptions of violent acts included verbal threats, serious assault and death threats. In addition to coercive measures and removal of patients from the ward, staff often dealt with these incidents using other active measures rather than passive defence or de-escalation. The main effects of violent incidents on staff were psychological and emotional. After violent incidents, staff had to continue caring for patients, and colleagues provided support. Support from managers was reported more rarely and staff expressed some dissatisfaction with the management.

CONCLUSIONS

As a primary prevention effort, it is important to raise awareness that external factors (organisational, situational and relational) are important causes of violence and may be easier to modify than internal patient factors. A secondary prevention approach could be to improve staff competence in the use of de-escalation techniques. An important tertiary prevention measure would be for management to follow up with staff regularly after violent incidents and to increase psychological support in such situations.

Feeling safe or unsafe in psychiatric inpatient care, a hospital-based qualitative interview study with inpatients in Sweden

Background

A major challenge in psychiatric inpatient care is to create an environment that promotes patient recovery, patient safety and good working environment for staff. Since guidelines and programs addressing this issue stress the importance of primary prevention in creating safe environments, more insight is needed regarding patient perceptions of feeling safe. The aim of this study is to enhance our understanding of feelings of being safe or unsafe in psychiatric inpatient care.

Methods

In this qualitative study, interviews with open-ended questions were conducted with 17 adult patients, five women and 12 men, from four settings: one general psychiatric, one psychiatric addiction and two forensic psychiatric clinics. The main question in the interview guide concerned patients' feelings of being safe or unsafe. Thematic content analysis with an inductive approach was used to generate codes and, thereafter, themes and subthemes.

Results

The main results can be summarized in three themes: (1) Predictable and supportive services are necessary for feeling safe. This concerns the ability of psychiatric and social services to meet the needs of patients. Descriptions of delayed care and unpredictable processes were common. The structured environment was mostly perceived as positive. (2) Communication and taking responsibility enhance safety. This is about daily life in the ward, which was often perceived as being socially poor and boring with non-communicative staff. Participants emphasized that patients have to take responsibility for their actions and for co-patients. (3) Powerlessness and unpleasant encounters undermine safety. This addresses the participants' way of doing risk analyses and handling unpleasant or aggressive patients or staff members. The usual way to act in risk situations was to keep away.

Conclusions

Our results indicate that creating reliable treatment and care processes, a stimulating social climate in wards, and better staff-patient communication could enhance patient perceptions of feeling safe. It seems to be important that staff provide patients with general information about the safety situation at the ward, without violating individual patients right to confidentiality, and to have an ongoing process that aims to create organizational values promoting safe environments for patients and staff.

Providing Good Care in the Shadow of Violence - An Interview Study with Nursing Staff and Ward Managers in Psychiatric Inpatient Care in Sweden

The aim was to describe the nursing staff and ward managers' experiences of safety and violence in everyday meetings with the patients. The qualitative content analyses resulted in four themes: the relationship with the patient is the basis of care; the organizational culture affects the care given; knowledge and competence are important for safe care; and the importance of balancing influence and coercion in care. The staff had a varied ability to meet patients in a respectful way. One way of creating a common approach could be to discuss and reflect upon different options in the meeting with the patient.

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.

Preventing and Reducing Coercive Measures-An Evaluation of the Implementation of the Safewards Model in Two Locked Wards in Germany

Introduction: Aggression and violence are highly complex problems in acute psychiatry that often lead to the coercive interventions. The Safewards Model is an evidence-informed conflict-reduction strategy to prevent and reduce such incidents. The aim of this study was to evaluate the implementation of this model with regard to coercive interventions in inpatient care. Materials and Methods: We evaluated outcomes of the implementation of the Safewards Model in two locked psychiatric wards in Germany. Frequency and duration of coercive interventions applied during a period of 10 weeks before and 10 weeks after the implementation period were assessed through routine data. Fidelity to the Safewards Model was assessed by the Organization Fidelity Checklist. Results: Fidelity to the Safewards Model was high in both wards. The overall use of coercive measures differed significantly between wards [case-wise: χ² (1, n = 250) = 35.34, p ≤ 0.001; patient-wise: χ² (1, n = 103) = 21.45, p ≤ 0.001] and decreased post-implementation. In one ward, the number of patients exposed to coercive interventions in relation to the overall number of admissions decreased significantly [χ² (1, 182) = 9.30, p = 0.003]. Furthermore, the mean duration of coercive interventions overall declined significantly [U(55,21) = -2.142, p = 0.032] with an effect size of Cohen's d = -0.282 (95% CI: -0.787, 0.222) in that ward. Both aspects declined as well in the other ward, but not significantly. Discussion: Results indicate that the implementation of the Safewards interventions according to the model in acute psychiatric care can reduce coercive measures. They also show the role of enabling factors as well as of obstacles for the implementation process.

Validating a Measurement Tool to Predict Aggressive Behavior in Hospitalized Youth

BACKGROUND: The aggression of hospital patients costs money and affects outcomes. Most methods to assess risk for aggression are developed for adults. This study recommends the use of a predictive tool, the Dynamic Appraisal of Situational Aggression-Youth Version (DASA-YV) to improve accuracy in identifying aggression risk in youth. AIMS: To determine if aggressive behavior of youth is better predicted with DASA-YV versus instinct. We sought to validate the feasibility of DASA-YV and determine its predictive validity for aggressive behavior in a youth-specific psychiatric hospital population, which could lead to prevention of aggression and improve interventions or outcomes. METHOD: After establishing interrater reliability of the DASA-YV, a 6-month pilot study with a prospective validation design compared aggressive behavior outcomes predicted with those that occurred within the next 24 hours. RESULTS: DASA-YV was found to be reliable and valid in predicting aggression in a youth population. CONCLUSIONS: Predicting aggression with the DASA-YV tool demonstrates a useful best practice application for psychiatric nurses that positively affects safety.

Violence committed against nursing staff by patients in psychiatric outpatient settings

Violence against nurses has increased particularly in psychiatric outpatient settings as psychiatric care shifts from being inpatient-based to being outpatient-based. Violence is a complex phenomenon that must be explored in different psychiatric nursing environments and settings. Violence in psychiatric outpatient settings should especially be explored as violence in this context has scarcely been examined. The aim of this systematic review was to elucidate violence committed against nursing staff by patients in adult psychiatric outpatient settings, based on reports from previous studies. A literature search was conducted in the CINAHL (EBSCO), Ovid MEDLINE, and PsycARTICLES (Ovid) databases. Fourteen studies emerged after the selection and quality assessment process. These studies indicated that violence in psychiatric outpatient settings is a multidimensional phenomenon comprising the reasons for, forms of, and consequences of violence. Reasons for violence could be related to the patient as well as to nursing staff. In psychiatric outpatient settings, verbal violence was the most common form of violence, and violence most frequently led to psychological consequences for nursing staff. The findings of this review highlight the importance of nursing staff developing skills and interventions for managing different kinds of violent situations. Given the multidimensional consequences of violence, attention must be given to the occupational well-being and coping ability of nursing staff at work. Furthermore, it would be worthwhile to compare cultural and intercountry differences of violent exposures in psychiatric outpatient settings.

Implementation of the Safewards model in public mental health facilities: A qualitative evaluation of staff perceptions

BACKGROUND

The Safewards model is gaining increasing acceptance in the mental health field in Australia and overseas. One of the most important goals of inpatient psychiatric services is to provide a safe and therapeutic environment for both patients and staff. However, this goal can be difficult to achieve if staff-patient interaction is not conducive to preventing violence and aggression.

OBJECTIVE

The purpose of this study was to explore nursing staff perceptions of the factors impacting on their capacity to establish Safewards in acute adult inpatient wards.

DESIGN

This study was guided by a phenomenological approach to develop a rich understanding of staff perceptions using semi-structured interviews.

SETTING AND SAMPLE

The setting was three acute mental health wards attached to general hospitals; one in a large provincial hospital and two in metropolitan hospitals in south-east Queensland. Interview participants were a purposive sample of fifteen registered nurses across each of the three wards.

METHOD

Semi-structured interviews were conducted at 12 months post-implementation of Safewards. The study was underpinned by Michie's integrative framework of behaviour change that helped identify target areas in order to enhance successful implementation of this model.

RESULTS

Content analysis of interview transcripts highlighted a range of factors including failure to address the difficulties encountered by some staff in engaging with Safewards interventions, lack of support from management, poor use of nurse educator time, the 'language' of Safewards, high acuity on the study wards, and staff and patient turnover.

CONCLUSION

This study highlights some difficulties with implementing Safewards and maintaining fidelity of the Safewards interventions in busy acute inpatient wards. Although these findings are from a qualitative study consisting of only 15 staff, our results indicate that efforts to implement Safewards need to address challenges faced by staff in engaging with the interventions, ensure buy-in from management, ensure adequate training and support during implementation and review training materials to ensure they fit with the local (i.e. Australian) context. Safewards provides an opportunity for a change in attitudes and development of a more therapeutic ward environment.

[Usefulness of Korean Version of Behavioral Cue Checklist for Predicting of Patient Violence in Emergency Departments]

PURPOSE

This study aimed to evaluate the usefulness of a behavioral cue checklist (BCC) containing 17 items developed by Wilkes et al. (2010) for identifying potentially violent patients in emergency departments.

METHODS

This was a prospective observational study to evaluate the usefulness of the Korean version of a BCC (K-BCC) as an assessment tool for predicting patient violence in emergency departments, and was conducted over 4 weeks in a regional emergency medical center located in B City. A total of 1,324 patients were finally analyzed.

RESULTS

Logistic regression analysis was performed to investigate whether each item of the K-BCC predicts violence, and a parsimonious set of 8 statistically significant items was selected for the tool. Receiver operating characteristic analysis of the BCC showed that the area under the curve was .97 (95% confidence interval: .94~1.0). The sensitivity, specificity, positive predictive value, and negative predictive value at the cut-off score of 2 were 75.6%, 98.9%, 68.2%, and 99.2%, respectively.

CONCLUSION

The K-BCC was found to be useful in predicting patient violence toward emergency department staff. This tool is simple, and fast to use and can play a significantly role identifying potentially violent patients. Owing to this advance identification, this tool can be helpful in preventing the potential for violence from manifesting as violent behaviors.

Recovery-focussed care: How it can be utilized to reduce aggression in the acute mental health setting

Consumer aggression is common in the acute mental health inpatient setting. Mental health nurses can utilize a range of interventions to prevent aggression or reduce its impact on the person and others who have witnessed the event. Incorporating recovery-focussed care into clinical practice is one intervention, as it fosters collaborative partnerships with consumers. It promotes their engagement in decisions about their care and encourages self-management of their presenting behaviours. It also allows the consumer to engage in their personal recovery as their mental health improve. Yet there is a paucity of literature on how nurses can utilize recovery-focussed care with consumers who are hospitalized and in the acute phase of their illness. In the present study, we report the findings of a scoping review of the literature to identify how recovery-focussed care can be utilized by nurses to reduce the risk of consumer aggression. Thirty-five papers met the inclusion criteria for review. Four components were identified as central to the use of recovery-focussed care with consumers at risk of becoming aggressive: (i) seeing the person and not just their presenting behaviour; (ii) interact, don't react; (iii) coproduction to achieve identified goals; and (iv) equipping the consumer as an active manager of their recovery. The components equip nurses with strategies to decrease the risk of aggression, while encouraging consumers to self-manage their challenging behaviours and embark on their personal recovery journey. Further research is required to evaluate the translation of these components clinically in the acute care setting.

A model for the facilitation of effective management of aggression experienced by Psychiatric Nurses from patients in a psychiatric institution

BACKGROUND

'The time I was hit nobody helped me. They (psychiatric nurses) just said: "you do not have to worry, you are not bleeding … in time you will see more"'. The core of the nursing profession is caring for those in need. However, when the psychiatric nurse (PN) is overwhelmed by aggression from the person cared for, the ideal of rendering quality patient care is compromised. There has to be a way to assist the PNs to manage aggression effectively in order to render quality patient care and improve PNs mental health.

OBJECTIVES

The purpose of this article is to describe the process that was followed in developing, describing and evaluating a model that could be used as a framework of reference to facilitate the effective management of aggression as an integral part of the mental health of PNs.

METHODS

A theory-generative, qualitative, exploratory, descriptive and contextual study design was used to develop the model. The central concept was derived from the Masters' research 'The lived experience of aggression and violence by PNs in a Gauteng psychiatric institution'. The process entailed the identification of the central concept, the definition of the central concept and other essential criteria and the classification of the central and related concepts. The conceptual framework was then described and evaluated.

RESULTS

The central concept was identified and the 'facilitation of effective self-management of aggression' was described and evaluated.

CONCLUSION

The conceptual framework may be able to assist PNs in managing aggression effectively, taking control of workplace environment.

Influence of staff's emotional reactions on the escalation of patient aggression in mental health care

Patient aggression is universally recognized as an important challenge in mental health care (MHC). Based upon a pragmatic exploration of the professional literature, we seek here to determine how negative emotional reactions of staff-including those conveyed in terms of fear, anger, and insult-may serve to exacerbate this serious impediment to safe and effective MHC. This is done using biological and evolutionary paradigms. Studies of patient aggression have tended to focus more on patient characteristics and behavior than on those of their caregivers. The authors suggest that patient aggression may be viewed as a response to "normal" interaction processes. The results of this investigation imply that the emotional reactions of staff may escalate the aggressive interaction by increasing the patient's perception of threat, and also, increase the probability of new incidents by creating a patient-staff relationship characterized by unsafety and mistrust. Mindfulness-based interventions are suggested as useful strategies to expand the staff's emotional awareness and increase emotional control.

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.

Inpatient aggression in community hospitals

Physical violence is a frequent occurrence in acute community psychiatry units worldwide. Violent acts by patients cause many direct injuries and significantly degrade quality of care. The most accurate tools for predicting near-term violence on acute units rely on current clinical features rather than demographic risk factors. The efficacy of risk assessment strategies to lower incidence of violence on acute units is unknown. A range of behavioral and psychopharmacologic treatments have been shown to reduce violence among psychiatric inpatients.

Demographics, clinical characteristics, and treatment of aggressive patients admitted to the acute behavioral unit of a community general hospital: a prospective observational study

OBJECTIVE

Aggressive patients are not uncommon in acute inpatient behavioral health units of general hospitals. Prior research identifies various predictors associated with aggressive inpatient behavior. This prospective observational study examines the demographic and clinical characteristics of aggressive inpatients and the routine medications these patients were receiving at discharge.

METHOD

Thirty-six adults diagnosed with a DSM-IV mental disorder who met 2 of 6 established inclusion criteria for high violence risk and a Clinical Global Impressions-Severity of Illness (CGI-S) scale score ≥ 4 were observed for a maximum of 28 days on the 23-bed case mix acute behavioral health unit of St Luke's University Hospital, Bethlehem, Pennsylvania, from January 2012 to May 2013. Primary outcome measures were the Modified Overt Aggression Scale (MOAS) and CGI-S; secondary measures were symptom outcome measures and demographic and clinical characteristics data. Analysis was conducted using repeated measures methodology.

RESULTS

Younger males with a history of previous violence, psychiatric admissions, and symptoms of severe agitation were more at risk for aggressive behavior. Positive psychotic symptoms, a diagnosis of bipolar disorder, substance use, and comorbid personality disorders also increased risk. Significant improvements from baseline to last visit were observed for the CGI-S and MOAS (P < .001 for both), with a significant correlation between the MOAS and CGI-S at last visit (P < .001). Only the symptom of agitation was significantly correlated to MOAS scores at both baseline and last visit (P < .001).

CONCLUSION

Patients significantly improved over time in both severity of illness and level of aggression.

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.

'Safe enough in here?': patients' expectations and experiences of feeling safe in an acute psychiatric inpatient ward

AIMS AND OBJECTIVES

To understand the experience of being a patient on an acute psychiatric inpatient ward.

BACKGROUND

Acute psychiatric inpatient care is an integral part of the mental health system. A key driver for admission to acute wards is risk. Previous research indicates that people do not always feel safe when in an acute ward. Understanding the patient experience of safety can influence nursing practice, as well as policy and service development.

DESIGN

A qualitative approach was used. Patient experience was conceptualised as represented through narrative as data. Sociolinguistic theories linking narrative structure with meaning informed the development of the analytic framework.

METHODS

Thirteen patients with a variety of diagnoses were recruited from an acute ward. Unstructured interviews were carried out in participants' homes two and six weeks postdischarge. Holistic analysis of each individual's data set was undertaken. Themes running across these holistic analyses were then identified and developed.

RESULTS

Participant narratives were focused around themes of help, safety and power. This study presents findings relating to the experience of safety. Participants expected to be safe from themselves and from others. Initially, they experienced a sense of safety from the outside world. Lack of knowledge of their fellow patients made them feel vulnerable. Participants expected the nurses to keep them safe, and felt safer when there were male nurses present.

CONCLUSIONS

Participants talk about safety in terms of psychological and physical safety. A key issue was the perception of threat from other patients, highlighting the need to consider patient safety as more than physical safety.

RELEVANCE TO PRACTICE

Nurses need to be sensitive to the possibility that patients feel unsafe in the absence of obvious threat. Institutional structures that challenge patients' sense of safety must be examined.

Understanding aggressive behaviour across the lifespan

Aggressive behaviour is the observable manifestation of aggression and is often associated with developmental transitions and a range of medical and psychiatric diagnoses across the lifespan. As healthcare professionals involved in the medical and psychosocial care of patients from birth through death, nurses frequently encounter - and may serve as - both victims and perpetrators of aggressive behaviour in the workplace. While the nursing literature has continually reported research on prevention and treatment approaches, less emphasis has been given to understanding the aetiology, including contextual precipitants of aggressive behaviour. This paper provides a brief review of the biological, social and environmental risk factors that purportedly give rise to aggressive behaviour. Further, many researchers have focused specifically on aggressive behaviour in adolescence and adulthood. Less attention has been given to understanding the aetiology of such behaviour in young children and older adults. This paper emphasizes the unique risk factors for aggressive behaviour across the developmental spectrum, including childhood, adolescence, adulthood and late life. Appreciation of the risk factors of aggressive behaviour, and, in particular, how they relate to age-specific manifestations, can aid nurses in better design and implementation of prevention and treatment programmes.

Determinants of seclusion after aggression in psychiatric inpatients

Some aggressive incidents in psychiatric wards result in seclusion, whereas others do not. We used the Staff Observation Aggression Scale-Revised and the mental health trust's database to identify determinants that predicted seclusion after aggression. These consisted of demographic, diagnostic, contextual, and aggression characteristics and were analyzed in a multilevel logistic regression. This showed associations between seclusion and aggression for the following: younger age, involuntary status, history of previous aggression, physical or dangerous violence, aggression being directed against objects, and a more severe incident. Thus, seclusion after aggression appears to be mainly predicted by aggression itself.

Registered nurses' and behavior health associates' responses to violent inpatient interactions on behavioral health units

BACKGROUND

Violence carried out by patients against nursing staff unsettles and threatens coworkers as they care for individuals admitted to inpatient psychiatric units.

OBJECTIVE

This study explored nursing staff's individual and group responses to violent incidents performed by patients against caregivers.

DESIGN

This qualitative study used focus groups to collect data from professional nurses and behavioral health associations (N = 19) recruited from urban, inpatient psychiatric unit. Data were analyzed thematically.

RESULTS

Sharing information about violence, intervening therapeutically, intervening nontherapeutically, recognizing team influences, experiencing emotions following violence, and understanding the work environment comprised the major themes of the experience.

CONCLUSIONS

Findings may stimulate discussions and education sessions that address strategies helpful to nursing staff so that incidents are prevented and staff is supported following such disturbing events. Events of workplace violence, including those occurring on behavioral mental health in inpatient units, require accurate individual and aggregate reporting to develop interventions and evaluate effectiveness of violence reduction strategies.

Control: patients' aggression in psychiatric settings

Psychiatric patient assaults on staff are a serious problem, affecting staff, patients, and organizations. To understand the etiology of aggressive events, researchers have documented characteristics of aggressive patients, their victims, and to a lesser degree, the patient-provider interaction. Missing in the literature is how staff's different perceptions of aggressive incidents might impact their reactions. In this study, we conducted in-depth, semistructured interviews with 11 health care professionals working in a psychiatric ward in one Israeli psychiatric hospital. Through content analysis, we revealed two main themes: patients' and providers' controllability over patients' aggression. From the intersection of these two themes, four prototypes of the aggressive encounter emerged: the power struggle, the therapeutic encounter, inverse power relations, and victim-to-victim encounters, each distinctively characterized by different emotional, cognitive, and behavioral responses. We discuss our findings in light of attribution theory, which carries important theoretical and practical implications for handling aggression.

Violent behavior in acute psychiatric inpatient facilities: a national survey in Italy

Violence committed by acute psychiatric inpatients represents an important and challenging problem in clinical practice. Sociodemographic, clinical, and treatment information were collected for 1324 patients (677 men and 647 women) admitted to Italian public and private acute psychiatric inpatient facilities during an index period in 2004, and the sample divided into 3 groups: nonhostile patients (no episodes of violent behavior during hospitalization), hostile patients (verbal aggression or violent acts against objects), and violent patients (authors of physical assault). Ten percent (N = 129) of patients showed hostile behavior during hospitalization and 3% (N = 37) physically assaulted other patients or staff members. Variables associated with violent behavior were: male gender, <24 years of age, unmarried status, receiving a disability pension, having a secondary school degree, compulsory admission, hostile attitude at admission, and a diagnosis of schizophrenia, bipolar disorder, personality disorder, mental retardation, organic brain disorder or substance/alcohol abuse. Violent behavior during hospitalization was a predictive factor for higher Brief Psychiatric Rating Scale scores and for lower Personal and Social Performance scale scores at discharge. Despite the low percentage of violent and hostile behavior observed in Italian acute inpatient units, this study shed light on a need for the careful assessment of clinical and treatment variables, and greater effort aimed at improving specific prevention and treatment programs of violent behavior.

Patient aggression in clinical psychiatry: perceptions of mental health nurses

Mental health nurses are faced with an increasing number of aggressive incidents during their daily practice. The coercive intervention of seclusion is often used to manage patient aggression in the Netherlands. However, GGZ Nederland, the Dutch association of service providers for mental health and addition care, has initiated a project to decrease the number of seclusions in clinical psychiatry. A first step in this project is to gain insight into the current situation: the perceived prevalence of patient aggression, the attitudes of mental health nurses towards patient aggression and those socio-demographic and psychosocial factors that contribute to the use of coercive interventions. A survey was undertaken among 113 nurses from six closed and semi-closed wards. In this survey, two questionnaires were used: (1) the Attitude Toward Aggression Scale; and (2) the Perceptions of the Prevalence of Aggression Scale. Variables derived from the Theory of Planned Behaviour were also measured. Nurses reported being regularly confronted with aggression in general and mostly with non-threatening verbal aggression. They perceived patient aggression as being destructive or offensive and not serving a protective or communicative function. The nurses generally perceived themselves as having control over patient behaviour (i.e. considerable self-efficacy) and reported considerable social support from colleagues. Although the nurses in this study were frequently confronted with aggression, they did not experience the aggression as a major problem.