Violence and aggression: a literature review

Systematic Aggression Registration in Forensic Psychiatric Care: A Qualitative Study on Preconditions for Successful Implementation

Available research emphasizes the importance of getting a systematic overview of inpatient aggression in forensic psychiatric care. However, the same research does not focus on how systematic aggression registration should be introduced in clinical practice. To facilitate the use of systematic aggression registration instruments, it is very relevant to gain insight into the perspective of staff members on the introduction of these instruments in daily clinical practice. Additionally, preconditions for achieving a successful implementation can be considered. Therefore, this study aims to gain insight into the perspective of the staff members on the implementation of a systematic aggression registration instrument-that is, the MOAS-in a forensic psychiatric unit. Interviews (n = 8) and a focus group with staff members were carried out. Three main themes: (1) creating the most appropriate context for introduction, (2) choice for the MOAS as relevant instrument, and (3) perpetuating the use of the MOAS in clinical practice are scrutinized. The mentioned preconditions can be used as guidelines when implementing systematic aggression registration in clinical practice. We hope that this paper can inspire other forensic psychiatric facilities to introduce systematic registration of aggressive incidents.

Mechanical Restraint in Inpatient Psychiatric Unit: Prevalence and Associated Clinical Variables

Background and Objectives: mechanical restraint (MR) is a controversial issue in emergency psychiatry and should be better studied to implement other alternative therapeutic interventions. The aim of this study was to estimate the prevalence of MR in an Italian psychiatric unit and identify the sociodemographic and clinical characteristics as well as the pharmacological pattern associated with MR. Materials and Methods: all subjects (N = 799) consecutively admitted to an Italian psychiatric inpatient unit were recruited. Several sociodemographic and clinical characteristics were recorded. Results: The prevalence of MR was 14.1%. Males, a younger age, and a single and migrant status were associated with the MR phenomenon. MR was more prevalent in patients affected by other diagnoses and comorbid illicit substance use, in patients with aggressive behaviors, and those that were involuntary admitted, leading significantly to hospitalization over 21 days. Furthermore, the patients that underwent MR were taking a lower number of psychiatric medications. Conclusions: Unfortunately, MR is still used in emergency psychiatry. Future research should focus on the dynamics of MR development in psychiatry, specifically considering ward- and staff-related factors that could help identify a more precise prevention and alternative intervention strategies.

An International Study on Violence and Aggression in Neuroscience Nursing

ABSTRACT

INTRODUCTION: The primary rationale for this study was to evaluate neuroscience registered nurses' (RNs') experience of violence and aggression internationally. The objectives were to determine how prevalent violence and aggression is in neuroscience nursing and the support and education provided. METHODS: Two online surveys were developed for neuroscience RN educators and RNs through SurveyMonkey. The questionnaires were distributed through RN organizations internationally in 2021. RESULTS: Two hundred seventy-two RNs responded to the survey. Most staff felt safe at work but had experienced some type of violence or aggression, with most experiencing verbal aggression. A variety of support existed for staff but lacked consistency, with some of the staff receiving more support from colleagues than their manager. Most RNs had received education in the management of violence and aggression, but some mentioned this was not specific to their neuroscience patient population, and most required further training. Thirty-one RN educators completed the survey, and the results were similar to those of the RN for education provision. Surprisingly, many neuroscience areas did not have a code system or personal alarms to alert staff to a violence or aggression emergency. CONCLUSION: Most RNs felt safe at work despite the high prevalence of violence and aggression experienced. Education was considered beneficial, but they desired more and further research into effective RN education. Effective support post incident needs to be determined. Protection for staff is paramount: few areas had code systems to raise an alarm for agitation, and few places of work had personal alarms that, if implemented, might enable a quicker response to prevent harm.

A Systematic Review of the Effectiveness of Safewards: Has Enthusiasm Exceeded Evidence?

Safewards is intended to be an evidence-based approach to reduce levels of conflict and containment in mental health inpatient settings. A systematic review was carried out to examine whether Safewards is effective in reducing conflict and containment events; and improving ward climate. Searches for articles evaluating the implementation of Safewards was conducted using PsycINFO, PubMed, Web of Science, Cochrane Library and CINAHL. Thirteen studies were included for review after applying inclusion and exclusion criteria. The Quality Assessment Tool for Studies with Diverse Designs (QATSDD) was used to assess study quality and the majority of studies (N = 7) were rated as "moderate" quality. Whilst there is evidence to suggest that Safewards is effective for reducing conflict and containment in general mental health services, there is insufficient high-quality empirical evidence to support its effectiveness in settings beyond this. Further research using robust methodological designs with larger, more representative samples is required in order for the effectiveness of Safewards to be established across the range of contexts in which it is currently being applied.

Prevalence and correlates of aggressive behavior in psychiatric inpatient populations

Aggressive behavior in patients with psychiatric disorders is attracting increasing research interest. One reason for this is that psychiatric patients are generally considered more likely to be aggressive, which raises a related question of whether diagnoses of psychiatric disorders predict the prevalence of aggressive behavior. Predicting aggression in psychiatric wards is crucial, because aggressive behavior not only endangers the safety of both patients and staff, but it also extends the hospitalization times. Predictions of aggressive behavior also need careful attention to ensure effective treatment planning. This literature review explores the relationship between aggressive behavior and psychiatric disorders and syndromes (dementia, psychoactive substance use, acute psychotic disorder, schizophrenia, bipolar affective disorder, major depressive disorder, obsessive-compulsive disorder, personality disorders and intellectual disability). The prevalence of aggressive behavior and its underlying risk factors, such as sex, age, comorbid psychiatric disorders, socioeconomic status, and history of aggressive behavior are discussed as these are the components that mostly contribute to the increased risk of aggressive behavior. Measurement tools commonly used to predict and detect aggressive behavior and to differentiate between different forms of aggressive behavior in both research and clinical practice are also reviewed. Successful aggression prevention programs can be developed based on the current findings of the correlates of aggressive behavior in psychiatric patients.

Aggression on the psychiatric ward: Prevalence and risk factors. A systematic review of the literature

INTRODUCTION

On psychiatric wards, aggressive behaviour displayed by patients is common and problematic. Understanding factors associated with the development of aggression offers possibilities for prevention and targeted interventions. This review discusses factors that contribute to the development of aggression on psychiatric wards.

METHOD

In Pubmed and Embase, a search was performed aimed at: prevalence data, ward characteristics, patient and staff factors that are associated with aggressive behaviour and from this search 146 studies were included.

RESULTS

The prevalence of aggressive behaviour on psychiatric wards varied (8-76%). Explanatory factors of aggressive behaviour were subdivided into patient, staff and ward factors. Patient risk factors were diagnosis of psychotic disorder or bipolar disorder, substance abuse, a history of aggression, younger age. Staff risk factors included male gender, unqualified or temporary staff, job strain, dissatisfaction with the job or management, burn-out and quality of the interaction between patients and staff. Staff protective factors were a good functioning team, good leadership and being involved in treatment decisions. Significant ward risk factors were a higher bed occupancy, busy places on the ward, walking rounds, an unsafe environment, a restrictive environment, lack of structure in the day, smoking and lack of privacy.

CONCLUSION

Despite a lack of prospective quantitative data, results did show that aggression arises from a combination of patient factors, staff factors and ward factors. Patient factors were studied most often, however, besides treatment, offering the least possibilities in prevention of aggression development. Future studies should focus more on the earlier stages of aggression such as agitation and on factors that are better suited for preventing aggression such as ward and staff factors. Management and clinicians could adapt staffing and ward in line with these results.

Mindful Melody: feasibility of implementing music listening on an inpatient psychiatric unit and its relation to the use of as needed medications for acute agitation

BACKGROUND

In this quality improvement project, we set out to study the effectiveness and feasibility of using music as an adjunct or replacement for pharmacologic agitation management on an inpatient psychiatric unit. We hypothesized music intervention would not only assist in de-escalation/calming of agitated patients, but also reduce overall administration of PRN medications on the unit.

METHOD

The project included 172 volunteer participants over 6 months: Three months without music available and 3 months with a music de-escalation option. During the latter period, patients were given the option of selecting a preferred music genre and provided with wireless headphones for up to 30 min. The number of as needed (PRN) medications administered for agitation and anxiety (including oral, sublingual, and intramuscular routes) was compiled from raw data using pharmacy records. Patients and nurses were provided with self-report surveys regarding the music intervention.

RESULTS

The average weekly PRN medication administrations decreased significantly during the 3 months with music for both haloperidol (8.46 [+/- 1.79, p < 0.05] to 5.00 [+/- 1.44, p < 0.05] administrations/week) and olanzapine (9.69 [+/- 2.32, p < 0.05] to 4.62 [+/- 1.51, p < 0.05] administrations/week), compared to the 3 months prior to music implementation. There was a non-significant increase in administration of lorazepam (3.23 [+/- 1.09, p < 0.05] to 6.38 [+/- 2.46, p < 0.05] average administrations/week). The patient survey responses were 96% positive (non-neutral; either agree or strongly agree with calming effect). Nurses agreed that the project was easy to implement; 56% agreed that music helped to calm patients down. Other exploratory outcomes included observed reductions in average length of hospital stay and number of seclusion events.

CONCLUSION

Music may play a significant role in reducing the utilization of PRN agitation medications on acute inpatient psychiatric units. More studies are needed to expand on these findings and explore the effect of PRN music on other therapeutic outcomes.

TRIAL REGISTRATION

Protocol registration NCT04514432 , retrospectively registered on 08/13/2020.

Aggressive and Disruptive Behavior Among Psychiatric Patients With Major Depressive Disorder, Schizophrenia, or Alcohol Dependency and the Effect of Depression and Self-Esteem on Aggression

Aggressive and disruptive behavior in inpatient settings poses a serious challenge for clinical staff and fellow patients. Hence, the aim of this study was to identify different aspects of aggressive and disruptive behavior in the context of an aberrant self-esteem or clinically manifested depression as potentially influencing factors. We collected self-reported data from 282 psychiatric patients [ICD-10 diagnoses for alcohol dependency, schizophrenia or major depressive disorder (MDD)] and compared it to healthy norm groups. As expected, all three patient groups scored higher in the aggression questionnaires than the norm group. Specifically, patients with MDD exhibited significantly higher externally directed aggression, reactive aggression, and irritability compared to controls. Patients with schizophrenia displayed higher irritability, while all three groups showed distinctly higher self-aggressiveness than healthy persons. We found a lower inhibition of aggression in alcohol dependent subjects compared to both the patient groups and the norm sample. Yet, the higher the self-esteem among alcohol dependent and MDD patients, the lower were their aggression scores; similarly, a lower self-esteem among patients diagnosed with schizophrenia resulted in heighten self-aggressiveness. Thus, our data suggests that therapeutic interventions for strengthening self-esteem in patients with a diagnosis of MDD, alcohol dependency or schizophrenia could reduce certain aspects of aggressive behavior. Therefore, it seems conceivable that strengthening self-esteem in psychiatric patients could contribute to the prevention of violence in clinical practice.

Risk Factors Associated With Inpatient Violence During Medium Security Treatment

Violence is a common phenomenon both in regular and forensic psychiatric settings, and has a profound impact on staff and other patients. Insight into the individual risk factors associated with violence in forensic psychiatric settings is rare and is therefore the subject of this research. A retrospective file study in three medium security units in Flanders was conducted to compare non-violent inpatients with inpatients who engaged in (verbal and physical) violent behavior. Binary logistic regression analyses were used to examine which variables contributed independently to the risk of violence. The results showed that absconding during treatment was independently associated with physical violence. A personality disorder diagnosis and general non-compliance with treatment were associated with verbal violence. Both types of violence predicted early termination of treatment. Contrary to previous research, the results from the risk assessment tools were not associated with inpatient violence. Clinical implications are discussed and include, among others, that clinicians should remain vigilant for early warning signs of non-compliance during treatment.

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.

Psychomotor agitation in subjects hospitalized for an acute exacerbation of Schizophrenia

The aims of this study were to establish the prevalence of moderate and severe psychomotor agitation in patients hospitalized for an active phase of schizophrenia, the associations between psychomotor agitation and patients' demographic and clinical variables, the intra-individual stability of the agitated/non-agitated dichotomy in independent psychotic breakdowns. The study was performed on a database relative to 630 inpatients hospitalized with a diagnosis of schizophrenia. Psychomotor agitation was measured with the Positive and Negative Syndrome Scale - Excited Component (PANSS-EC). Prevalence of moderate and severe psychomotor agitation was 40.5% and 23.7%, respectively. Non-agitated patients were older, with longer illness history and duration of untreated psychosis, were more frequently on antipsychotic medication, had lower incidence of recent use of substances, and functioned better before the index hospitalization than moderately and/or severely agitated patients. Non-agitated patients had lower scores for total PANSS and Emsley's positive and anxiety dimensions. Compared with the severely agitated group, non-agitated and moderately agitated patients scored more in Emsley's depression dimension. Poor functioning before index hospital admission, higher scores for negative subscale and Emsley's positive dimension and use of substances exerted an effect on risk of psychomotor agitation.

Incidence and risk factors of workplace violence on psychiatric staff

BACKGROUND

A study by Hesketh et al. found that 20% of psychiatric nurses were physically assaulted, 43% were threatened with physical assault, and 55% were verbally assaulted at least once during the equivalent of a single work week. From 2005 through 2009, the U.S. Department of Justice reported that mental health occupations had the second highest average annual rate of workplace violence, 21 violent crimes per 1,000 employed persons aged 16 or older.

OBJECTIVE

An evaluation of risk factors associated with patient aggression towards nursing staff at eight locked psychiatric units.

PARTICIPANTS

Two-hundred eighty-four nurses in eight acute locked psychiatric units of the Veterans Health Administration throughout the United States between September 2007 and September 2010.

METHODS

Rates were calculated by dividing the number of incidents by the total number of hours worked by all nurses, then multiplying by 40 (units of incidents per nurse per 40-hour work week). Risk factors associated with these rates were analyzed using generalized estimating equations with a Poisson model.

RESULTS

Combining the data across all hospitals and weeks, the overall rate was 0.60 for verbal aggression incidents and 0.19 for physical aggression, per nurse per week. For physical incidents, the evening shift (3 pm - 11 pm) demonstrated a significantly higher rate of aggression than the day shift (7 am - 3 pm). Weeks that had a case-mix with a higher percentage of patients with personality disorders were significantly associated with a higher risk of verbal and physical aggression.

CONCLUSION

Healthcare workers in psychiatric settings are at high risk for aggression from patients.

Experiences of Patients in Acute and Closed Psychiatric Wards: A Systematic Review

PURPOSE

To obtain insight into the patients' experiences during treatment in an acute, closed psychiatric ward.

DESIGN AND METHODS

A systematic literature search was conducted in the databases Medline, Embase, CINAHL, and Cochrane.

FINDINGS

Ten articles were selected. Four main themes emerged from the literature: (a) the inappropriate use of the ward rules, (b) nurses' lack of time for interacting with patients, (c) the feeling of humiliation, and (d) the involvement of significant others.

PRACTICE IMPLICATIONS

Nurses can use the findings of this systematic review to improve quality of care in acute psychiatric units.

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.

Violent behaviour in a forensic psychiatric hospital in Finland: an analysis of violence incident reports

The aim of this paper was to explore the frequency and provocation of physically violent incidents in a Finnish forensic psychiatric hospital. Three years (2007-2009) of violent incident reports were analysed retrospectively. The data were analysed by content analysis, and statistically by Poisson regression analysis. During the study period a total of 840 incidents of physical violence occurred. Six main categories were found to describe the provocation of violence where three of these categories seemed to be without a specified reason (61%), and three represented a reaction to something (36%). The risk for violent behaviour was highest for the civil patients (RR = 11.96; CI 95% 9.43-15.18; P < 0.001), compared to criminal patients (RR = 1). The civil patients represented 36.7% of the patients, and in 43.6% of the studied patient days, they caused 89.8% of the reported violence incidents. Patients undergoing a forensic mental examination did not frequently behave aggressively (RR = 1.97; CI 95% 0.91-4.28). These results can be used in the reorganization of health-care practices and the allocation of resources.

Validation of the Violence Risk Screening-10 instrument among clients discharged from a psychiatric hospital in Beijing

The Violence Risk Screening-10 is one of the few instruments available for evaluating violence risk in mental health clients during and after hospitalization. This prospective study examined the applicability of this brief instrument with a sample of 289 clients in the 6 months after discharge from a general psychiatric hospital in Beijing. During the research period, 24 of the 289 clients demonstrated aggression. The receiver-operator characteristic curve yielded an area under the curve of 0.62. At the cut-off point of 4.5, its sensitivity/specificity was 79.2%/33.3%, and the corresponding positive/negative predictive value was 9.9%/94.5%. The predictive accuracy of this instrument was lower compared with the results of the original study, and was also less accurate than when it was administered while the clients were in the hospital. While promising in its utility for use beyond the hospital, it deserves further modification prior to its wide use across culturally-diverse China.

Kennedy Axis V: Clinimetric properties assessed by mental health nurses

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

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.

Retrospective review of trends in assaults and seclusion at an acute psychiatric ward over a 5-year period

In developing countries such as South Africa, not much is known about the prevalence of assaults and seclusion occurring in mental health wards over time. Here, we describe a 5-year trend in assaults and seclusions, stratified by gender, at Stikland Hospital, South Africa. A retrospective review of clinical records of patients admitted to the acute psychiatric admission wards at Stikland and involved in assault and secluded was undertaken between 1 January 2005 and 31 December 2010. Data on the number of patient and staff assaults as well as seclusions, gender, age, marital status, level of education, level of income, duration of hospital admission and primary psychiatric diagnosis were collected. Significantly (P < 0.01) more men than women engaged in patient assaults, while significantly (P < 0.01) more men were secluded than women. On a monthly basis, the number of gender-stratified patient assaults and seclusions significantly increased (P < 0.01) throughout the study period. In conclusion, we show here that gender had a significant effect on both patient assault and seclusion numbers, which increased towards the end of the study period. Monitoring of these events is therefore important to continuously improve quality of care.

Closing an open psychiatric ward: organizational change and its effect on staff uncertainty, self-efficacy, and professional functioning

PURPOSE

Converting an open psychiatric ward to a closed one can be threatening and stressful for the medical and nursing staff involved. This study describes the effects of this change, in particular the before-after correlation among self-efficacy, professional functioning, and uncertainty.

DESIGN AND METHODS

Forty-four staff participated, completing pre-/poststructured questionnaires.

FINDINGS

Uncertainty was higher before the conversion than after the conversion. Professional functioning declined after the conversion. Self-efficacy was positively correlated with pre- and postconversion functioning, but negatively correlated with postconversion uncertainty.

PRACTICE IMPLICATIONS

It is important to prepare staff for this significant organizational change. Suggestions for prechange interventions are offered.

Measurement of predictive validity in violence risk assessment studies: a second-order systematic review

The objective of the present review was to examine how predictive validity is analyzed and reported in studies of instruments used to assess violence risk. We reviewed 47 predictive validity studies published between 1990 and 2011 of 25 instruments that were included in two recent systematic reviews. Although all studies reported receiver operating characteristic curve analyses and the area under the curve (AUC) performance indicator, this methodology was defined inconsistently and findings often were misinterpreted. In addition, there was between-study variation in benchmarks used to determine whether AUCs were small, moderate, or large in magnitude. Though virtually all of the included instruments were designed to produce categorical estimates of risk - through the use of either actuarial risk bins or structured professional judgments - only a minority of studies calculated performance indicators for these categorical estimates. In addition to AUCs, other performance indicators, such as correlation coefficients, were reported in 60% of studies, but were infrequently defined or interpreted. An investigation of sources of heterogeneity did not reveal significant variation in reporting practices as a function of risk assessment approach (actuarial vs. structured professional judgment), study authorship, geographic location, type of journal (general vs. specialized audience), sample size, or year of publication. Findings suggest a need for standardization of predictive validity reporting to improve comparison across studies and instruments.

Climate control: creating a multifaceted approach to decreasing aggressive and assaultive behaviors in an inpatient setting

Creating an environment that is safe for everyone is a goal for all inpatient mental health units. How to address the aggressive and assaultive behaviors is the challenge. This article discusses how using a multidisciplinary team with a variety of approaches can help create a culture that supports safety.

Aggression in psychiatry wards: a systematic review

Although fairly frequent in psychiatric in-patient, episodes of aggression/violence are mainly limited to verbal aggression, but the level of general health is significantly lower in nurses who report 'frequent' exposure to violent incidents, and there is disagreement between patients and staff concerning predictors of these episodes. We searched the Pubmed, Embase and PsychInfo databases for English, Italian, French or German language papers published between 1 January 1990 and 31 March 2010 using the key words "aggress*" (aggression or aggressive) "violen*" (violence or violent) and "in-patient" or "psychiatric wards", and the inclusion criterion of an adult population (excluding all studies of selected samples such as a specific psychiatric diagnosis other than psychosis, adolescents or the elderly, men/women only, personality disorders and mental retardation). The variables that were most frequently associated with aggression or violence in the 66 identified studies of unselected psychiatric populations were the existence of previous episodes, the presence of impulsiveness/hostility, a longer period of hospitalisation, non-voluntary admission, and aggressor and victim of the same gender; weaker evidence indicated alcohol/drug misuse, a diagnosis of psychosis, a younger age and the risk of suicide. Alcohol/drug misuse, hostility, paranoid thoughts and acute psychosis were the factors most frequently involved in 12 studies of psychotic patients. Harmony among staff (a good working climate) seems to be more useful in preventing aggression than some of the other strategies used in psychiatric wards, such as the presence of male nurses.

Support Our Staff--a unique program to help deal with patient assault

PURPOSE

The program "Support Our Staff" was developed to provide assaulted staff with the most current information and coping strategies.

CONCLUSIONS

Participants reported being helped by the program and felt better prepared to cope with future assaults. However, victims felt blamed for the disruption caused by the assault and resented the lack of support from management.

PRACTICE IMPLICATIONS

Management needs to take responsibility for their role in violence within the institution, allowing staff to escape the isolation and guilt. Reporting must be encouraged and staff asked to contribute to the development of efficient programs, thus leading to a sense of empowerment.

Overcrowding in psychiatric wards and physical assaults on staff: data-linked longitudinal study

BACKGROUND

Patient overcrowding and violent assaults by patients are two major problems in psychiatric healthcare. However, evidence of an association between overcrowding and aggressive behaviour among patients is mixed and limited to small-scale studies.

AIMS

This study examined the association between ward overcrowding and violent physical assaults in acute-care psychiatric in-patient hospital wards.

METHOD

Longitudinal study using ward-level monthly records of bed occupancy and staff reports of the timing of violent acts during a 5-month period in 90 in-patient wards in 13 acute psychiatric hospitals in Finland. In total 1098 employees (physicians, ward head nurses, registered nurses, licensed practical nurses) participated in the study. The outcome measure was staff reports of the timing of physical assaults on both themselves and ward property.

RESULTS

We found that 46% of hospital staff were working in overcrowded wards, as indicated by >10 percentage units of excess bed occupancy, whereas only 30% of hospital personnel were working in a ward with no excess occupancy. An excess bed occupancy rate of >10 percentage units at the time of an event was associated with violent assaults towards employees (odds ratio (OR) = 1.72, 95% CI 1.05-2.80; OR = 3.04, 95% CI 1.51-6.13 in adult wards) after adjustment for confounding factors. No association was found with assaults on ward property (OR = 1.06, 95% CI 0.75-1.50).

CONCLUSIONS

These findings suggest that patient overcrowding is highly prevalent in psychiatric hospitals and, importantly, may increase the risk of violence directed at staff.

Nurses' experience of adjusting to workplace violence: a theory of adaptation

Workplace violence directed at nurses working in both the mental health and general areas of the hospital is a common occurrence and the impact of these events on all parties may be severe. A consequence of these confronting situations is the possibility that nurse victims will leave the profession. To help administrators facilitate nurses' psychological recovery, this qualitative study identified how nurses in several areas of a hospital setting adapted to workplace violence, research which has been previously unexamined. This study was the first of its kind to use a theory of cognitive adaptation to explore nurses' experiences of workplace violence. Participants were found to use the cognitive processes of finding meaning, gaining mastery and enhancing the self to adapt to workplace violence. Critical incident debriefing may facilitate the nurse victim's psychological recovery following an episode of workplace violence.

The first step in the validation of a new screen for violence risk in acute psychiatry: The inpatient context

BACKGROUND

Instruments for evaluating the risk of violence towards others have mostly been developed for assessment of risk for recidivism into violent crime in forensic psychiatry. In general psychiatry there is a considerable need for specialised, brief and structured assessment tools to inform risk decisions.

METHOD

The study aimed to validate a brief structured clinical risk assessment screen of inpatient violence (V-RISK-10), a 10-item structured clinical checklist with a good vignette-based interrater reliability (ICC=0.87). In this study it was used for risk assessment of a one-year sample of patients (N=1.017) admitted to two acute psychiatric units. Risk assessments at admission were compared to prospective records of aggressive and violent acts during the hospital stay.

RESULTS

Results showed a base rate for aggression of 9%. The predictive validity of the V-RISK-10 was estimated by Receiver Operating Characteristics (ROC). It yielded an area under the curve (AUC) of 0.83, with sensitivity/specificity of 0.81/0.73 and corresponding positive and negative predictive values (PPV/NPV) of 0.24/0.97. The screen was easy-to-use and showed a short completion time.

CONCLUSION

Despite promising results further validation studies are required before the V-RISK-10 is adopted into routine clinical practise.

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.

Safety and security in acute admission psychiatric wards in Ireland and London: a comparative study

AIMS AND OBJECTIVES

The comparative element of this study is to describe safety and security measures in psychiatric acute admission wards in the Republic of Ireland and London; to describe differences and similarities in terms of safety and security patterns in the Republic of Ireland and London; and to make recommendations on safety and security to mental health services management and psychiatric nurses.

BACKGROUND

Violence is a serious problem in psychiatric services and staff experience significant psychological reactions to being assaulted. Health and Safety Authorities in the UK and Ireland have expressed concern about violence and assault in healthcare, however, there remains a lack of clarity on matters of procedure and policy pertaining to safety and security in psychiatric hospitals.

DESIGN

A descriptive survey research design was employed.

METHODS

Questionnaires were circulated to all acute wards in London and in Ireland and the resulting data compared.

RESULTS

A total of 124 psychiatric wards from London and 43 wards from Ireland were included in this study and response rates of 70% (London) and 86% (Ireland) were obtained. Differences and similarities in safety and security practices were identified between London and Ireland, with Irish wards having generally higher and more intensive levels of security.

CONCLUSIONS

There is a lack of coherent policy and procedure in safety and security measures across psychiatric acute admission wards in the Republic of Ireland and London. Given the trends in European Union (EU) regulation, there is a strong argument for the publication of acceptable minimum guidelines for safety and security in mental health services across the EU.

RELEVANCE TO CLINICAL PRACTICE

There must be a concerted effort to ensure that all policy and procedure in safety and security is founded on evidence and best practice. Mental health managers must establish a review of work safety and security procedures and practices. Risk assessment and environmental audits of all mental health clinical environments should be mandatory.