A prospective study of patient assaults on nurses in a provincial psychiatric hospital in Canada

Behavioral skills training for teaching safety skills to mental health service providers compared to training-as-usual: a pragmatic randomized control trial

BACKGROUND

Violence in the healthcare workplace has been a global concern for over two decades, with a high prevalence of violence towards healthcare workers reported. Workplace violence has become a healthcare quality indicator and embedded in quality improvement initiatives of many healthcare organizations. The Centre for Addiction and Mental Health (CAMH), Canada's largest mental health hospital, provides all clinical staff with mandated staff safety training for self-protection and team-control skills. These skills are to be used as a last resort when a patient is at imminent risk of harm to self or others. The purpose of this study is to compare the effectiveness of two training methods of this mandated staff safety training for workplace violence in a large psychiatric hospital setting.

METHODS

Using a pragmatic randomized control trial design, this study compares two approaches to teaching safety skills CAMH's training-as-usual (TAU) using the 3D approach (description, demonstration and doing) and behavioural skills training (BST), from the field of applied behaviour analysis, using instruction, modeling, practice and feedback loop. Staff were assessed on three outcome measures (competency, mastery and confidence), across three time points: before training (baseline), immediately after training (post-training) and one month later (follow-up). This study was registered with the ISRCTN registry on 06/09/2023 (ISRCTN18133140).

RESULTS

With a sample size of 99 new staff, results indicate that BST was significantly better than TAU in improving observed performance of self-protection and team-control skills. Both methods were associated with improved skills and confidence. However, there was a decrease in skill performance levels at the one-month follow-up for both methods, with BST remaining higher than TAU scores across all three time points. The impact of training improved staff confidence in both training methods and remained high across all three time points.

CONCLUSIONS

The study findings suggest that BST is more effective than TAU in improving safety skills among healthcare workers. However, the retention of skills over time remains a concern, and therefore a single training session without on-the-job-feedback or booster sessions based on objective assessments of skill may not be sufficient. Further research is needed to confirm and expand upon these findings in different settings.

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.

The Relationship between Training and the Experience of Aggression in the Workplace in Residential Care Staff Working in Learning Disability Services

The present study used a questionnaire to examine the following in 50 social care staff: the experience of workplace aggression in staff supporting individuals with a learning disability, the extent to which staff had received training in the prevention and management of aggressive behaviour and the relationship between training and staff confidence in dealing with aggression. The majority of staff were found to have experienced assault in the course of their work. Despite this, less than half had received training in the prevention and management of aggression. Such training seemed to impact differently on males and females, with trained males feeling confident in managing aggression, and untrained males feeling anxious. In contrast, the majority of females reported feelings of anxiety regardless of previous training. Staff reported strategies for dealing with aggression which mainly involved withdrawal of themselves and others rather than physical interventions. However, there was a neglect of longer-term strategies for dealing with aggression. Implications for practice are discussed.

Gender Differences in Assault Levels in a Health Service Unit for People with Learning Disabilities and Severely Challenging Behaviour

The present study examines gender differences and levels of threatened, attempted and actual assaults on staff working in a health service in-patient unit for individuals with learning disabilities over a 35-month period. It was found that the staff experienced high levels of assault overall, but that women experienced significantly higher levels of both threatened and total assaults as compared with men. Implications of the findings are discussed.

Investigating the influence of contextual factors in the coordination of chronic mental illness care in a district health system

Background

The global shift from institution-based to community-based care for chronic mental illness (CMI) care resulted in the de-institutionalization of clients with CMI. However, health systems which have been originally designed for acute hospital-based care do not seem to be appropriately transformed to manage CMI care at a community level.

Aim

The aim of this study was to investigate how contextual factors influenced care coordination for chronic mental illness care within the eThekwini District.

Methods

This study employed a qualitative multiple case study design with instrumental approach. Maximum variation sampling was used to select five Community Health Centres (CHC's) and 48 health providers who worked with mentally ill clients in the sample CHC's. Framework analysis was used to analyze the results.

Results

Inequitably resourced catchment areas, unclear referral systems, high staff turnover, freezing of posts, chronic staff shortage and adverse working conditions contributed to care fragmentation, poor client care and client loss in the system. On the other hand, limited community support systems constituted barriers for client reintegration into society and relapses.

Conclusion

The study concluded that the eThekwini District health facility settings were not adequately equipped to respond to care coordination demands for chronic mental illness care.

Design for an Art Therapy Robot: An Explorative Review of the Theoretical Foundations for Engaging in Emotional and Creative Painting with a Robot

Social robots are being designed to help support people’s well-being in domestic and public environments. To address increasing incidences of psychological and emotional difficulties such as loneliness, and a shortage of human healthcare workers, we believe that robots will also play a useful role in engaging with people in therapy, on an emotional and creative level, e.g., in music, drama, playing, and art therapy. Here, we focus on the latter case, on an autonomous robot capable of painting with a person. A challenge is that the theoretical foundations are highly complex; we are only just beginning ourselves to understand emotions and creativity in human science, which have been described as highly important challenges in artificial intelligence. To gain insight, we review some of the literature on robots used for therapy and art, potential strategies for interacting, and mechanisms for expressing emotions and creativity. In doing so, we also suggest the usefulness of the responsive art approach as a starting point for art therapy robots, describe a perceived gap between our understanding of emotions in human science and what is currently typically being addressed in engineering studies, and identify some potential ethical pitfalls and solutions for avoiding them. Based on our arguments, we propose a design for an art therapy robot, also discussing a simplified prototype implementation, toward informing future work in the area.

Injuries and Assaults in a Long-Term Psychiatric Care Facility: An Epidemiologic Study

The objectives of this study were to document the high rates of acute injuries and physical assaults among nurses and certified nursing assistants working in long-term psychiatric care facilities and to identify risk factors for assaults and injuries to inform prevention strategies. A mixed-design cohort study was conducted. Acute injury and physical assault data were obtained from administrative records. Using staff rosters and schedule records, incidence rates were calculated by job title, gender, shift, and floor. Rates were also reported by severity, body part, type, and nature. Targeted interviews with staff members provided measures of physical lifting and resident combativeness. Injury rates were calculated by degree of lifting and assault rates were calculated by degree of resident combativeness. Overall rates of injuries (55.6 per 100 person-years) and assaults (67.3 per 100 person-years) were substantially higher than expected. Predictably, injuries were associated with resident lifting and assaults were associated with contact with combative residents. A higher risk of assault was found among women and higher risks of injury and assault were observed among full-time employees compared to per diem or pool agency workers. In addition, weekend shifts were found to have a higher rate of injuries and a lower rate of assaults than weekday shifts. In similar longterm care facilities with psychiatric populations, efforts should be made to reduce lifting and avoid circumstances that agitate residents. Work organization factors should be taken into consideration when developing interventions.

Physical injury and workplace assault in UK mental health trusts: An analysis of formal reports

Workplace violence is a significant problem for health service personnel, with National Health Service (NHS) workers subject to 68 683 physical assaults between 2013 and 2014. Almost 70% of assaults occur in the mental health sector, and although serious, non-fatal injury is rare, the individual and economic impact can be substantial. In the present study, we analysed mandatory incident reports from a national database to examine whether there were identifiable precursors to incidents leading to staff injury, and whether staff characteristics were associated with injury. In line with previous descriptions, we found injury occurred either as a direct result of patient assault or during physical interventions employed by staff to contain aggression. Importantly, we found little evidence from staff reports that patients' symptoms were driving aggression, and we found less evidence of patient perspectives among reports. We make several recommendations regarding the reporting of these events that could inform policy and interventions aimed at minimizing the likelihood of injury.

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.

Psychiatric illness and resident assaults among veterans in long-term care facilities

This article describes a quality improvement program to reduce the prevalence of physical assaults in a university-affiliated, 234-bed Veterans Affairs (VA) long-term care (LTC) facility, which experienced a rise in the number of physical assaults to >4 per 1,000 bed days of care in four LTC units. Analysis of 55 events (29 patients) at this VA LTC site during 2007 revealed 19 resident assailants (8% total population), 10 victims, and 30% repeat events. Of the residents who exhibited assaultive behavior, 44% had dementia and 32% had schizophrenia as a major diagnosis. Following a process improvement plan, new occurrence assaultive behaviors declined from >4 to <1 per 1,000 bed days and remained low during 5-year follow up.

The antecedents of violence and aggression within psychiatric in-patient settings

OBJECTIVE

To systematically review the types and proportions of antecedents of violence and aggression within psychiatric in-patient settings.

METHOD

Empirical articles and reports with primary data pertaining to violence and aggression within adult psychiatric in-patient settings were retrieved. For each study, prospective antecedent data were extracted. The extracted antecedent data were thematically analysed, and all higher-level themes were meta-analysed using rate data.

RESULTS

Seventy-one studies met the inclusion criteria, from which 59 distinct antecedent themes were identified and organised into nine higher-level themes. The higher-level antecedent theme 'staff-patient interaction' was the most frequent type of antecedent overall, precipitating an estimated 39% of all violent/aggressive incidents. An examination of the staff-patient interaction themes revealed that limiting patients freedoms, by either placing some sort of restriction or denying a patient request, was the most frequent precursor of incidents, accounting for an estimated 25% of all antecedents. The higher-level themes 'patient behavioural cues' and 'no clear cause' also produced other large estimates and were attributed to 38% and 33% of incidents overall.

CONCLUSION

This review underscores the influence that staff have in making in-patient psychiatric wards safe and efficacious environments.

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.

The incidence and risk factors of workplace violence towards female nurses reported via internet in an acute psychiatric hospital

The authors conducted a prospective follow-up study to explore incidence and risk factors related to workplace violence towards nurses. Seventy-seven volunteers were recruited to complete a baseline questionnaire. Participants then used a designated Web site to report violent incidents they encountered during a 6-month period. A generalized estimating equation was used for data analysis. A total of 74 members completed the study; 456 events were reported. The incidence rates of various types of violence are reported in this paper. Risk factors for violence included short duration of employment, marital status, and a high level of anxiety. Strategies to reduce future violence from psychiatric patients include preplacement education that targets this high-risk group of nurses and efforts to reduce the staff anxiety levels.

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.

Hospital staff responses to workplace violence in a psychiatric hospital in Taiwan

We surveyed 222 nurses, nursing assistants, and clerks at a psychiatric hospital in Taiwan on responses to workplace violence, treatment of violent patients, and reporting behavior. Staff reported 78 incidents of physical violence (PV), 113 of verbal abuse (VA), 35 of bullying/ mobbing (BM), 21 of sexual harassment (SH), and 10 of racial harassment (RH) over the course of one year. Among affected staff, only 31% of those experiencing PV and < 10% of those experiencing other categories of violence completed a formal report. Highest levels of reporting to senior staff were among those affected by SH. Patients who were physically violent were more likely to be injected with medication than patients showing other violent behaviors. More VA-affected staff considered the incident not important enough to report. Other reasons for not reporting the incident were fear of negative consequences, especially for BM, and shame for SH. Reliable systems for responding to and reporting patient violence should be developed.

Workplace violence on workers caring for long-term institutionalized schizophrenic patients in Taiwan

It has been noted that workplace violence most frequently occurs in psychiatric settings. The purpose of this study was to explore the workplace violence, including violence situation, victims' feeling, and the prevention strategies, on workers caring for long-term institutionalized schizophrenic patients in Taiwan. We conducted a face-to-face, in-depth, and semi-structured interview with 13 health care workers suffering from physical violence and/or sexual harassment by patients in 2002. First, the interviews were taped and/or paper-notes recorded, then transcribed, organized, and analyzed. Results found that all of the victims alleged they did not receive enough post-incident support, and more than a half of the victims could not call others for help during the violence. To avoid further attack, most victims offered prevention strategies which were considered valuable for establishing guidelines. However, some victims regarded workplace violence as inevitable and part of the job. The most common situations of workplace violence were during routine ward inspections, especially when the victims were alone. The most serious psychological harm was post-traumatic stress disorder (PTSD). In conclusion, we recommended a re-engineering of the organization to a supportive and safe working environment for prevention of workplace violence in the study hospital.

Violence and aggression: a literature review

This paper reports the results of a literature review that was undertaken to provide background for a small pilot study that introduced violence measurement instruments that was to assist the development of nursing practice on an acute psychiatric unit. Multiple databases were searched, focusing on publications since 1994: CINAHL, Ovid Healthstar, Ovid MEDLINE (R), EMBASE, and PsycINFO. The search used the following four groups of key word alternatives (used in truncated form to allow for ending permutations) in combination with each other: violence, aggression, dangerous; prediction, assessment, factor, risk, issue, cause, reason; mental, psychiatric; inpatient, short-term, acute, admission. Searching was supplemented with footnote chasing of those papers retrieved and existing resources of the first author. Consequently, the synthesis of the results discussed cannot be considered a systematic review of the literature and is a reflection of some of the key issues found in the literature.

Relationship between assault frequency and length of hospitalization in older patients with dementia--determining the maximum benefit of inpatient treatment

In this quantitative study, the author examined the relationship between duration of hospitalization and frequency of assaultive behavior in 42 older long-term patients with dementia in a Canadian psychiatric hospital. The study instrument used for data collection was existing incident reporting forms routinely completed in Canadian regional psychiatric hospitals. A secondary analysis was conducted using data previously collected on a regular basis by the psychiatric hospital serving as the study site. A significant negative correlation was found between the number of assaults committed and the number of months spent in the hospital, with significantly fewer assaults occurring in the second year of hospitalization compared with the first year. Male patients were observed to be significantly more assaultive than female patients. Findings suggest that the maximum benefit for patients hospitalized for assaultive behavior is obtained during the first 2 years of inpatient treatment and that patients within this population who are no longer assaultive may be more appropriately cared for in nursing homes. Based on these findings, resources should be allocated to assist with the transition of formerly assaultive patients with dementia from a psychiatric hospital to a nursing home. This scenario forecasts the development of a challenging new role for nurses.

Aggressive behaviour on acute psychiatric wards: prevalence, severity and management

AIM

This paper reports a study to investigate the nature and prevalence of inpatient aggressive behaviour directed at staff and other patients and, in the case of patient self-harm, the methods used by nursing staff to manage this.

BACKGROUND

Aggressive behaviour poses a threat to the physical and psychological health of psychiatric nursing staff. The fear that results from working in a climate of potential danger can also have a damaging impact on patient care.

METHODS

Nursing staff on five acute inpatient wards in one hospital in the United Kingdom collected data on aggressive incidents using the Staff Observation Aggression Scale - Revised during a 10 month period from June 2001 to April 2002.

RESULTS

There were 254 incidents of aggression recorded. Staff were most commonly targeted and were involved in 57 x 1% of incidents. The most frequent provocation of the aggression was the patient being denied something such as leave from the ward (29 x 5% of incidents). The most frequent means used by patients was verbal aggression (60% of incidents), the most frequent outcome for the victim was feeling threatened (59% of incidents), and verbal interventions were used most frequently to manage the aggressive behaviour (43 x 7%). Despite many incidents involving verbal aggression in both staff- and patient-targeted aggression, 35 x 9% of incidents involving staff and 25% of incidents involving other patients resulted in seclusion.

CONCLUSION

It is estimated that in a 12 month period at the hospital in this study a nurse would have a one in 10 chance per year of receiving any kind of injury as a result of patient aggression. Despite the predominance of verbal over physical aggression, the fear generated from working in such an environment and a difficulty in understanding the causes of patient aggression may motivate staff to manage aggressive incidents with physical methods such as seclusion and restraint on a frequent basis.

Junior staffing changes and the temporal ecology of adverse incidents in acute psychiatric wards

AIM

This paper reports an examination of the relationship between adverse incident rates, the arrival of new junior staff on wards, and days of the week on acute psychiatric wards.

BACKGROUND

Incidents of violence, absconding and self-harm in acute inpatient services pose risks to patients and staff. Previous research suggests that the arrival of inexperienced new staff may trigger more adverse incidents. Findings on the relationship between incidents and the weekly routine are inconsistent.

METHOD

A retrospective analysis was conducted of formally reported incident rates, records of nursing student allocations and junior doctor rotation patterns, using Poisson Regression. Variance between days of the week was explored using contingency table analysis. The data covered 30 months on 17 psychiatric wards, and were collected in 2002-2004.

FINDINGS

The arrival of new and inexperienced staff on the wards was not associated with increases in adverse incident rates. Most types of incidents were less frequent at weekends and midweek. Incident rates were unchanged on ward-round days, but increased rates were found on the days before and after ward rounds.

CONCLUSION

Increased patient tension is associated with raised incident rates. It may be possible to reduce incident rates by moderating stimulation in the environment and by mobilizing support for patients during critical periods.

Cross-cultural differences in psychiatric nurses' attitudes to inpatient aggression

Little is currently known about the attitudes of psychiatric nurses toward patient aggression, particularly from an international perspective. Attitudes toward patient aggression of psychiatric nurses from five European countries were investigated using a recently developed and tested attitude scale. Data were collected from a convenience sample of 1,769 student nurses and psychiatric nurses. Regression analysis was performed to identify personal and occupational characteristics of the respondents able to predict their attitude toward aggression. Analysis of variance was used to identify significant differences in attitudes between and among countries. Attitude was predicted by sex, contractual status (full vs. part time), and the type of ward on which subjects worked. With one exception (communicative attitude), attitudes differed across countries. More research on attitude formation is needed to determine which factors account for these differences.

Prediction of inpatient violence

OBJECTIVE

An overview of studies on predictors and on the accuracy of prediction of inpatient violence should be given.

METHOD

To date, the published data do not allow a systematic meta-analysis due to different sample characteristics, different measures and definitions of violence, and different time frames of observation. Published studies were reviewed regarding significant predictors of inpatient violence.

RESULTS

Predictors of violence in institutional settings are different from predictors of violence in the community: variables such as sex, age, diagnosis and alcohol abuse play a minor role, while clinical and psychopathological variables are prominent. Only history of violence is a robust static predictor. The total level of positive and general psychotic symptoms seems to enhance the violence risk of inpatients, whereas results concerning specific features like delusions or command hallucinations are contradictory due to inevitable problems of sample selection. The accuracy of clinical predictions is better than chance but limited by the effects of therapeutic interventions and research artefacts.

CONCLUSION

The author argues that more precise determinations of the violence risk in institutions will fail and that the role of environmental factors has often been underestimated.

Evaluating risk factors for violence at the inpatient unit level: combining young adult patients and those with mental retardation

The current study demonstrates the use of patient case mix to evaluate the probability of aggression occurring on an inpatient psychiatric unit. The impact of combining young adult psychiatric patients with patients classified with mental retardation on the overall negative events and injuries on an inpatient psychiatric unit was evaluated. Results suggest when the combined number of young adults and patients classified with mental retardation exceeds 10 the unit is at high risk for aggressive behavior occurring. Recommendations for evaluating violence at a unit level using case mix are provided.

Precipitants of elderly psychiatric patient assaults on staff: preliminary empirical inquiry

Although there have been several studies of the characteristics of psychiatric patient assailants, there have been only six comprehensive, empirical assessments of precipitants to these assaults and no precipitant study has focused solely on elderly psychiatric patient assailants. This one and one-half year, retrospective study continued the inquiry into the nature of patient assault precipitants and focused only on elderly assailants. Older, male patients with a diagnosis of schizophrenia and histories of violence toward others and substance use disorder physically assaulted primarily male, mental health workers. These staff victims experienced disruptions in the domains of mastery, attachment, and meaning as well as the symptomatology associated with psychological trauma. The most common precipitants to these assaults were denial of services and acute psychosis. The findings and implications for health care providers in long-term care settings where elderly psychiatric patients reside are discussed.

Decreasing Assault Occurrence on a Psychogeriatric Ward

An agitation management model providing staff education, quantitative assessment of agitation, and emphasized psychosocial interventions was introduced on a geriatric psychiatry ward for male patients. A within-subjects comparison was made of Cohen-Mansfield Agitation Inventory (CMAI) scores and frequency of committing assault under pre- and post-intervention conditions. Among participants (N = 8) who finished the 72-week study, CMAI scores did not differ significantly under either of the study conditions (p > .05, two-tailed t test). Twenty-nine assaults occurred during the pre-intervention time period and six assaults occurred during the post-intervention time period. According to analysis with the Wilcoxon signed ranks test, the distribution of assaults differed significantly between the two time periods (p < .05, two-tailed). Among individuals who were excluded from the intervention because of lack of consent, assaults increased over the same two time periods. Psychosocial interventions intended to reduce agitation among elderly men with dementia may not necessarily serve to decrease agitation, but may serve to decrease assault occurrence.

Discourses of blame: accounting for aggression and violence on an acute mental health inpatient unit

The English National Service Framework for Mental Health stipulates that the highest quality of health care should be provided for mental health service users in the most efficient and effective manner. Incidents of aggression and violence militate against achieving that goal, yet such incidents are frequently reported in inpatient settings. Traditionally, research in this area has focused on the extent of the phenomenon, the individual characteristics of those involved and precursors to the incident. For the most part the literature reflects a dualistic, perpetrator/victim conceptualisation of incidents. This study aimed to address the lack of research undertaken from a more systemic perspective by examining how all those involved understood and attributed meaning to violent or aggressive situations and how these attributions justified individual perceptions, reactions and actions. Working from the position that all behaviour, including violent behaviour, has meaning to those involved and can be understood, 16 semi-structured interviews were carried out in one mental health unit. Because only one client was both willing and able to give a full account of an incident, we focus here on two incidents in which that client was involved. Discourse analytic techniques were used to examine her account of the two incidents and those of the staff members involved. Participants discussed key themes from the interviews in terms of several dilemmas: whether the violent or aggressive behaviour was 'mad' or 'bad'; predictable or unpredictable; and had resulted from 'personality' or ' mental illness'. The client and staff discourses were strikingly similar and in each case the central concern was with the attribution of blame. The findings have implications for the professional discourse of mental health care, including the discourse of the current policy agenda, a discourse itself constructed with the primary function of exoneration from and attribution of blame.

Staff's attitudes to the use of restraint and seclusion in a Norwegian university psychiatric hospital

A questionnaire-based study examining the experiences and attitudes of staff to restraint and seclusion in a Norwegian university psychiatric hospital demonstrated that a majority of staff believed the interventions were used correctly. Staff at wards with high usage of restraint and seclusion, and male staff, were most critical to how often the interventions were used. Most staff favoured the use of physical restraint, although they believed it was the intervention patients were least favourable to. Highly educated staff were not more critical to the use of restraint and seclusion than other staff. Despite the fact that a majority of staff believed that using restraint and seclusion made patients calmer and did not cause aggression, anxiety or injuries, about 70% had been assaulted by patients in connection with the interventions. Many staff believed the use of restraint and seclusion violated patients' integrity, could harm the provider-patient alliance and could frighten other patients. Violence, self-harm and threats were given as main reasons for the use of restraint. Increased staffing and more attention by level-of-care staff were cited as the most important strategies for reducing the use of restraint and seclusion. There is a need for informing all staff about the negative effects of restraint and seclusion and for training staff in less restrictive ways in dealing with aggressive and violent patients.

Medicate, restrain or seclude? Strategies for dealing with violent and threatening behaviour in a Norwegian university psychiatric hospital

The aim of this study was to examine staff strategies for applying emergency procedures with patients who were violent or threatening. The study addressed those situations where verbal intervention, voluntary medication, and other interventions had been tried unsuccessfully and where staff found it necessary to apply emergency procedures in the shape of forced emergency medication (pharmacological restraint), physical restraint, and seclusion. The study was conducted in a 100-bed Norwegian university psychiatric hospital. By retrospectively examining hospital records we found there were 797 episodes of physical restraint, 384 episodes of pharmacological restraint, and 88 episodes of seclusion during a five and a half year period. The preferred emergency procedures varied significantly with patients' sex, age, and diagnoses. Physical restraint was preferred more often with male, younger, and nonpsychotic patients. Pharmacological restraint was preferred more often with female patients and older patients with a nonorganic psychotic disorder. Seclusion was preferred more often with older male patients with an organic psychotic disorder.

Risk factors for psychiatric inpatient assaults on staff

The risk of psychiatric patient assaults on staff members is increasing yearly, with resultant increases in employee victim suffering, medical expense, and lost productivity. Traditionally considered a clinician responsibility, the management of patient violence also has important administrative implications. This article presents a review of the risk factors associated with violence that includes the characteristics of patients who assault but adds the characteristics of employee victims of such assaults as well as contextual variables. Additional data from a two-year study of a peer-help crisis intervention program for employee victims of patient assaults are included. The mental health administrative implications of this approach are outlined.

Assaultive behaviour in psychiatrically hospitalized elderly: a response to psychosocial stimulation and changes in pharmacotherapy

The objective of this naturalistic, non-experimental study was to observe and evaluate the relationship between psychosocial stimulation and changes in medications, and the emergence of the assaultive behaviour, as well as its 24-h course, in a psychogeriatric ward. The assaultive behaviour in 29 patients (mean age 73.9 years) was rated daily for three consecutive months. Major psychosocial stimuli and the number of medication changes were also recorded. More patients with organic brain syndromes than with non-organic conditions were aggressive. Those with organic syndromes were more likely to become aggressive within any 24 h period and their aggression was less likely to disappear. The rate with which aggression emerged changed following changes in psychotropic medications. The presence of psychosocial stimulation and changes in non-psychotropic medications modified the rate of disappearance of the aggression. In a psychogeriatric inpatient population, both prevalence and incidence of aggression, as well as its response to modifying factors, depends critically on pathogenesis. The emergence and disappearance of aggression are modified by different factors.

Clinician safety

Clinician safety is a serious concern for health care professionals because of the great risk of violence in health care workplaces, especially emergency and mental health departments. Assaults on mental health staff are often encountered from patients who are intoxicated with, or suffering withdrawal symptoms from, substances. Additionally, violence toward mental health professionals is frequently encountered from patients diagnosed with paranoid schizophrenia, personality disorders, learning disabilities, and mental retardation. Incidents of assault are often ignored by victims and administrators. Administrators must implement several measures to prevent clinician assault.

Risk factors for assaults on nursing staff: childhood abuse and education level

OBJECTIVES

This study examined risk factors for nursing staff associated with being assaulted in the workplace and described the prevalence of staff assaults on patients.

BACKGROUND

Most studies examining assaults in the workplace examine patient variables. Scant empirical investigation has occurred of staff variables.

METHODS

A random mailed survey measuring physical and psychological assaults, sexual assault, and trauma history was employed. Childhood abuse and education were unique predictors of physical and sexual assault by patients. The results also revealed that staff members sometimes abuse patients.

IMPLICATIONS

These results can help inform the training and supervision of nursing staff. Strategies to decrease staff vulnerability of being assaulted may reduce the risk. The finding that education also may be a protective factor has important implications for trends in managed care to downsize nursing. Protecting patients and staff are important administrative priorities in the workplace.

The organizational context of non-lethal workplace violence: its interpersonal, temporal, and spatial correlates

This article examines 993 violent incidents involving faculty, students, and staff that occurred at a highly ranked teaching and research university and its affiliated medical center. Violent incidents were included in the sample if they involved faculty, students, or staff, regardless of their specific location or context (i.e., whether they occurred on campus and/or off-campus and whether they occurred within the context of work or some other activity). The theoretical goal of the project was to compare work-related incidents with non-work-related incidents of interpersonal violence occurring in a single, multifunctioning, and professionally hierarchical organization. Data were collected over a 7-year period from three police departments (city, county, and university), university records, and criminal history records obtained from the state police. The coding protocol was developed to capture crime-scene information pertinent to each of the incidents. This included information about the victim, the perpetrator, the relationship between the victim and perpetrator, and the violent incident. The data were examined using nonparametric statistics and logistic regression to model predictive differences between the workplace and non-workplace incidents. The results suggest that the workplace incidents of violence differ from the non-workplace incidents according to their time, victim age, degree of victim injury, and whether the workplace is a medical location. The authors conclude that these differences are better explained by the movement of people in and out of the workplace who bring societal violence with them, rather than by a category or type of workplace violence.

Aggressive behaviour in the elderly

In this paper, the literature on aggressive behaviour in the elderly is reviewed, with emphasis on: definition; study samples; patient groups; study designs and methodology; data collection; instruments used to measure aggressive behaviour; social, clinical, demographic and biological correlates; prevalence and rates; precipitants; outcome; site; timing; daily and seasonal variation; patterns of usage of hospitals and other institutions; stuffing levels, staff morale, staff attitudes, staff training and other staffing factors.

Staff assaults and injuries in a psychiatric hospital as a function of three attitudinal variables

Although the available research makes reference to the connection between staff attitudes and patient assault, solid evidence of the connection is lacking. This investigation sought to examine 3 attitudinal variables that in the literature seemed to have the strongest relation to staff assaults and injuries. External locus of control, anxiety, and authoritarianism on the part of staff were examined in relation to the experience of assaults and injuries. A sample of 78 staff members working at a psychiatric hospital responded to a survey; results indicated an associative relationship between both a more external locus of control and high trait anxiety and employees' experience of work-related injuries. Associations also were noted between both locus of control and authoritarianism and employees' frequency of assault and injury experiences. The findings provide important information that suggests that locus of control, authoritarianism, and trait anxiety on the part of staff members are connected with patient assaults and injuries.

A prospective study of assaults on staff by psychiatric in-patients

This study determined the prevalence and features of assaults on staff, compared them with other aggressive incidents by psychiatric in-patients, and studied their relationship with the ward atmosphere. There were 181 physical assaults among 279 staff in two months, i.e. 389 assaults per 100 staff per year. A few patients were responsible for the majority of the assaults. Most assaults were triggered off by staff-patient interaction. About one-third of the staff were significantly psychologically shaken by the incidents. Patients were more likely to be provoked and used more severe means of aggression against staff than against other targets of aggression. There were no significant differences between the characteristics of patients who assaulted staff and those who had other targets of aggression.

A multinational study of psychiatric nursing staffs' beliefs and concerns about work safety and patient assault

In an effort to understand beliefs and concerns about work safety and patient assault, the author describes the results of a multinational survey of 999 nursing staff members working in psychiatric facilities across the United States, Canada, United Kindgom, and South Africa. Although the majority of the sample (75%) reported being physically assaulted at least once during their careers, 62% responded that they felt safe in their work environment most of the time. Significant differences were found among the nurses with regard to beliefs about adequacy of staffing, safety of the physical environment, admission of assaultive patients, expectations about being victims of assault, overall level of safety, and taking legal action against a patient. A significant difference in attitudes was also found among nursing staff members, who reported previous assaults. They believed that assaults are expected events in their work with psychiatric patients.

An observational study of associations between nurse behaviour and violence in psychiatric hospitals

A cyclical model of violence to psychiatric nurses is proposed in this paper and a partial test of the model is reported. The model suggests that stress induced by exposure to violence leads to impaired staff performance and adoption of behaviours which make the re-occurrence of violence more likely. We tested the proposal that certain staff behaviours (e.g. expressing verbal hostility) are associated with an increased risk of assault by observing nurse-patient interaction on 12 psychiatric wards (n = 103 nurses). The verbal and physical interaction of (1) assaulted staff, (2) staff on violent wards, and (3) staff in grades which experience high levels of assault, were compared with those of respective low risk groups. There was some evidence of an association between interaction patterns and violence. We conclude this paper by discussing the implications of the model for psychiatric nursing practice.

Assaults by patients: the experience and attitudes of psychiatric hospital nurses

Four hundred and twenty-five nurses working in a 420 bed metropolitan psychiatric hospital were asked to complete a questionnaire about their experience of physical assault by patients and their attitude toward the problem. 61% returned the questionnaire. The overall mean annual rate of assault per nurse was 2.0, with student psychiatric nurses (mean 6.7) significantly more at risk than any other group. Nurses working in the psychogeriatric area reported more than double the rate of assaults reported by nurses working in rehabilitation services. 60% of respondents were female; there were very few sex differences in attitudes to assault. Overall, nurses reported a high tolerance for assault, although they recognised it as an experience that was often very traumatic psychologically. Views about managing assaultiveness differed widely, and this lack of consensus probably hinders the development of optimal strategies to deal with what is a major problem in many psychiatric units.