Aggression Management Training Research Articles

A Review on Violent Behavior among Patients Admitted in Psychiatric Setting

Introduction: Prevalence of violent incidents-physical or verbal directed to self or others, is a serious problem in psychiatric setting1. Violent behavior in psychiatric unit affects the safety of patients and any other team member working in that particular setting. There is evidence that majority of the nurses working in psychiatric setting have been attacked by patients at least one time in their career.2 Aim: To estimate the prevalence of aggression and violence among clients admitted in psychiatric units and also to find out the factors associated with aggressive and violent behavior. Materials & method: A comprehensive search was made on ProQuest, CINAHL, PubMed, Google scholar, and Cochrane databases for published original research articles between 1990 and 2016. We included all types of studies that reported about incidence or prevalence of violent behavior and factors associated with it in psychiatric ward. Result: Twenty one studies were eligible for meta-analysis and the overall pooled prevalence of violence among patients admitted in psychiatric ward is 16% (0.13. 0.19, CI 95%, i-squared=97.9%, p=0.000). The review also examined the causes accompanying with violent behavior. Conclusion: Violent behavior in psychiatric setting appear to be extremely variable between different settings. Assessing prevalence of violent behavior and to find out factors associated with violent behavior are a vital part of developing aggression management and violence prevention training program to safeguard clients and staffs from violent behavior.

A Comparison of the Evolution and Entropy of Responses to Picture Choices on an “Absurdum Questionnaire” between Members of Two Different Training Groups

The results of previous studies on a group-training program for group therapists supported the influence of group dynamics on the members’ individual choices of pictures presented to them in an “absurdum questionnaire.” The present analysis compared the responses obtained from previous studies with those from a group of psychiatric caregivers training to prevent and manage aggression of hospitalized patients. The evolution of the number and entropy of the responses to the picture choices were compared. The group analysis program was conducted at the Basque Foundation for the Investigation of Mental Health in Bilbao, Spain. The Preventive Approach and Controlled Intervention program for the prevention and management of aggression was held in Geneva, Switzerland. Data were collected from the participants in the group-analysis program during their 11 sessions of training and from those in the aggression prevention and management program during three days of a series of four-day courses. The participants were presented with an “absurdum questionnaire” containing 50 pairs of images, and were asked to choose one image from each pair. The evolution of the number of answers was not significantly different between the two training groups. The evolution of entropy revealed a clear difference with a gradual increase in the group-analysis program, and a decrease in the aggression-management training group. We interpret this difference in light of Bion’s view of group dynamics, with the group-analysis training being driven by Bion’s basic assumptions and the aggression-management training by Bion’s work group.

The participant's perspective: learning from an aggression management training course for nurses. Insights from a qualitative interview study.

Aggression management training for nurses is an important part of a comprehensive strategy to reduce patient and visitor aggression in healthcare. Although training is commonplace, few scientific studies examine its benefits. To explore and describe, from a nurse's perspective, the learning gained from attending aggression management training. This was a descriptive qualitative interview study. We conducted semi-structured individual interviews with seven nurses before (September/October 2012) and after they attended aggression management training (January/February 2013). Interview transcripts were content-analysed qualitatively. The study plan was reviewed by the responsible ethics committees. Participants gave written informed consent. Aggression management training did not change nurses' attitude. Coping emotionally with the management of patient and visitor aggression remained a challenge. Nurses' theoretical knowledge increased, but they did not necessarily acquire new strategies for managing patient/visitor aggression. Instead, the course refreshed or activated existing knowledge of prevention, intervention and de-escalation strategies. The training increased nurses' environmental and situational awareness for early signs of patient and visitor. They also acquired some strategies for emotional self-management. Nurses became more confident in dealing with (potentially) aggressive situations. While the training influenced nurses' individual clinical practice, learning was rarely shared within teams. Aggression management training increases skills, knowledge and confidence in dealing with patient or visitor aggression, but the emotional management remains a challenge. Future research should investigate how aggression management training courses can strengthen nurses' ability to emotionally cope with patient and visitor aggression. More knowledge is needed on how the theoretical and practical knowledge gained from the training may be disseminated more effectively within teams and thus contributed to the creation of low-conflict ward cultures.

Care Providers Experience of Violence in Psychiatric Setting

Nurses working in psychiatric setting experience violence from patients. This semi-structured interview explored psychiatric nurses’ experience of patient violence in psychiatric setting. Data collected from 90 nurses working in 8 hospitals of DK and Udupi Districts of Karnataka. Data was collected using a 24 item semi-structured interview guided questions. Descriptive statistics was used for analysis. The result showed that 84% of the nurses experienced verbal violence and 58% of the nurses experienced physical assault from patients. The study concludes that aggression management and violence prevention training program must be organized for nurses working in psychiatric setting.

The construction of context-mechanisms-outcomes in realistic evaluation.

To discuss the construction of context-mechanisms-outcomes (CMOs) developed as part of a realistic evaluation study of two aggression management training programmes. Realistic evaluation draws on theories and methods derived from the social sciences. It provides a distinctive account of the nature of programmes and how they work. Realistic evaluation is a form of evaluation that is driven by theory, and was based by Pawson and Tilley ( 1997 ) on the philosophy of critical realism. Critical realism is an important perspective in modern philosophy and social science, but it is largely absent in the field of healthcare research. This paper provides a critical discussion on the construction of CMOs as part of a realistic evaluation study. This paper draws on the personal experiences of the author in using realistic evaluation to evaluate training in aggression management. Realistic evaluation stresses four key linked concepts for explaining and understanding programmes: 'mechanism', 'context', 'outcome pattern' and 'context-mechanisms-outcomes (CMO) pattern configuration'. A CMO configuration is a proposition stating what it is about an initiative that works, for whom and in what circumstances. In this way, the effectiveness of the programme is understood, with an explanation of why the outcomes developed as they did and how the programme was able to react to underlying mechanisms and in what contexts. Therefore, a realistic evaluation researcher is not just inspecting outcomes to see if an initiative (implementation) works, but is analysing the outcomes to discover if the conjectured mechanism or context theories are confirmed. This analysis provides not only evidence of effectiveness, but also an explanation that helps to develop and improve the content and the targeting of future programmes. The development of CMOs requires a great deal of skill on the part of the researcher and requires a flexibility of approach when collecting and analysing the data and in understanding the topic being investigated. Applications of realistic evaluation have focused largely on evaluating initiatives in the field of social policy and, more recently, social work practice. To date, however, there have been few published realistic evaluation studies within nursing; therefore this study is novel in its use of the methodology.

Professional nurses' knowledge and skills in the management of aggressive patients in a psychiatric hospital in the Western Cape

Aggression and violence by patients towards psychiatric nurses are a global issue. Professional nurses working in psychiatric hospitals are required to look after psychiatric patients who may become aggressive. They may not be equipped to deal with aggression as the focus of nursing is on patient care, thus they may not have the necessary skills and knowledge to intervene in aggressive episodes. A quantitative approach, descriptive design was used to determine the knowledge and skills of professional nurses in managing aggression of psychiatric patients. The study was conducted in a psychiatric hospital in the Western Cape. The target population consisted of 119 professional nurses working in the psychiatric hospital. An all-inclusive sample of professional nurses was selected to complete a self-developed structured questionnaire. The overall Cronbach's Alpha for the instrument was 0.721. A total of 70 questionnaires were handed out, yielding a return of 52 completed questionnaires. The response rate was74%. Data analysis was done using SPSS version 22 from which descriptive data was obtained. Findings suggest that nurses are likely to be exposed to verbal aggression as opposed to sexual aggression. Nurses with less years of experience had more knowledge than experienced nurses who have been in practice longer. Nurses who had training in aggression management reported that it did not meet their needs. Overall, the findings revealed that nurses have good (above 80) knowledge about management of aggressive psychiatric patients. There is a need for on-going in-service training and refresher courses in the management of aggression. There should be a needs analysis prior to the commencement of the training.

Effect of aggression management training program on knowledge and attitudes of nurses working at psychiatric clinics

Objective: The purpose of this study was to determine the effect of Aggression Management Training Program (AMTP) on knowledge levels and aggression perceptions of nurses working at psychiatric inpatient clinics in Kayseri/Turkey. Methods: This study was conducted with 27 nurses who participated to the AMTP as the one group pretest-posttest experimental design. Data were collected by using Personal Information Form, Perception of Aggression Scale, and Assessment Form of Knowledge Levels of Nurses Regarding Aggression Management. AMTP was carried out interactively with totally 3 groups including 2 groups (10 participants in each group) and 1 group of 7 participants. Knowledge levels and perceptions of aggression of nurses were evaluated before, after and three months after AMTP. Results: In this study, AMTP was found to increase knowledge level of nurses and led to positive changes at their aggression perceptions. Conclusion: Consequently, it was determined that AMTP increased knowledge levels of nurses working at psychiatric clinics and provided positive changes at their aggression perceptions. It could be recommended to continue training on aggression management with regular intervals.

Patient and visitor violence towards staff on medical and psychiatric wards in India

BackgroundPatient and visitor violence (PVV) towards staff is common across health settings. It has negative effects on staff and treatment provision. Little data is available from the developing world. AimsTo examine the prevalence of PVV in India and make comparisons with the existing data. MethodsWe administered an abbreviated version of the Survey of Violence Experienced by Staff (SOVES-A) in English in Mysore on medical and psychiatric wards. Results249 staff participated. 16% of staff in psychiatric wards were subjected to some form of PVV in the past 4 weeks which is lower than in the developed world. 57% of staff on medical wards experienced PVV which is similar to the developed world. Patients and Visitors were almost equal sources of this violence. Verbal abuse was more common than threats and physical assaults. Training in aggression management may be a protective factor. ConclusionPVV is a significant problem in India, especially on medical wards. Aggression management training may be a way to reduce the prevalence of PVV.

Dealing with aggressive behaviour in nursing homes: caregivers’ use of recommended measures

To identify groups of caregivers in terms of their use of measures for dealing with resident aggression and the differences between these groups related to their characteristics. Caregivers in nursing home are confronted with a major challenge when faced with the aggressive behaviour of residents. Therefore, the application of recommended measures is important in supporting caregivers and promoting safety for residents. Cross-sectional survey. A total of 804 caregivers working in 21 Swiss nursing homes provided data. The questionnaire used was based on published recommendations regarding management of aggressive behaviour and amendments by experts. The most widely used measure aimed to calm down the resident and to understand the meaning of aggressive behaviour. Physical activities were applied by around 50% of the respondents, and interdisciplinary case reviews as well as standardised instruments for assessment and documentation were used by <50%. Caregiver characteristics such as employment level, support from superiors, institutionalised support for affected caregivers and training in aggression management are associated with their use of recommended measures. Furthermore, caregivers' competence in empathising with the residents' perspective in connection with their professional experience has a positive influence on applying recommended measures. Caregivers use multifaceted measures in understanding the meaning of underlying aggression, but there is a certain failure to use standardised instruments. Caregivers differ significantly in the frequency of their application of recommended measures. Support from superiors and assistance for affected caregivers positively influence their use of measures, whereas training in aggression management leads to less use. Findings show the importance of support from superiors and institutionalised assistance for affected caregivers. Caregiver competence in empathising with the residents' perspective is important in using person-centred approaches in the care of residents with aggressive behaviour.

Percentage prevalence of patient and visitor violence against staff in high-risk UK medical wards

Patient and visitor violence adversely affects staff and organisations; however, there are few UK data about patient and visitor violence on medical wards. Therefore, we conducted a cross-sectional study using a validated tool (Survey of Violence Experienced by Staff) in six medical wards in three North Wales district general hospitals to assess the prevalence of violence against healthcare staff. A total of 158 staff responded (12 men, 144 women, two not stated). We found that, within the previous 4 weeks, 83% of staff had experienced verbal aggression, 50% had been threatened and 63% had been physically assaulted. Of those assaulted, 56% sustained an injury, with three requiring medical assessment or treatment. Length of experience in the workplace correlated negatively with verbal abuse, but not with threats or assaults. Direct patient contact positively correlated with more overall incidents. There was no correlation between training in aggression management and the experience of incidents. Healthcare support workers and nurses reported a higher prevalence of patient and visitor violence compared with other groups of health worker.

Risk factors associated with patient and visitor violence in general hospitals: Results of a multiple regression analysis

BackgroundPatient and visitor violence (PVV) is the most dangerous occupational hazard that health professionals must contend with. Staff training is recommended to prevent and manage PVV. There is minimal research focusing on risk factors associated with PVV in general hospital settings. Therefore, staff training is mostly based upon expert knowledge and knowledge from psychiatric and emergency settings. ObjectivesThis study investigates health professionals’ experiences with PVV in order to describe risk factors related to PVV that occur in general hospital settings. DesignA retrospective cross-sectional survey was conducted in 2007. SettingA university general hospital in Switzerland. Participants2495 out of 4845 health professionals participated (58.0% nurses & midwives, 19.2% medical doctors, 3.6% physical therapists, occupational therapists & nutritionists, 6.1% ward secretaries, medical & radiology assistants, 6.3% nursing assistants or less qualified nursing staff and 5.1% other staff). All had direct patient contact and 82% were female. MethodsData were collected via questionnaires using the Survey of Violence Experienced by Staff German-Version-Revised, the German version of the shortened Perception of Aggression Scale and the Perception of Importance of Intervention Skills Scale. Descriptive statistics and multiple logistic regression analyses were used. ResultsRisk factors associated with PVV depend upon the form of violence. Those trained in aggression management and/or those who work predominantly with patients over 65years of age experience twice as much PVV as others. Health professionals working in emergency rooms, outpatient units, intensive care units, recovery rooms, anesthesia, intermediate care and step-down units also experience PVV more often. When health professionals are older in age, are from the medical profession, are students, or when they have an attitude rating preventive measures as being less important and aggression as emotionally letting off steam, they experience less PVV. ConclusionTraining could change the perception and the recognition of PVV, and could therefore increase the risk of experiencing PVV. The health professionals’ specific occupation along with attitude and age, the patients’ age, the communication and the workplace are all relevant risk factors. Further studies should investigate the impact of aggression management training and other measures that would reduce PVV.

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

Workplace violence, including patient-perpetrated violence in healthcare settings, is increasingly being recognized as preventable. Staff training has been identified as a necessary component of any initiative aimed at preventing or reducing incidents of aggression and violence in the workplace. This narrative review of the literature evaluates the effectiveness of staff training programs designed to prevent and manage violence and aggression in psychiatric hospitals. An exhaustive review of the literature was performed on all articles published in English between January 1, 1990 and April 1, 2007 that evaluate an aggression management training program. Twenty-nine studies met the inclusion criteria for a full review and were summarized using a qualitative narrative approach. Aggression management training has been proven effective in some areas, such as reducing the use of restraints and other coercive control devices, but more methodologically rigorous research is needed to firmly establish whether it is effective in reducing aggression and staff injuries. The findings of this study suggest that relying too heavily on aggression management staff training will have limited effect on addressing the range of issues related to patient-perpetrated violence in psychiatric hospitals. Mental healthcare organizations must look beyond staff training if they are to achieve meaningful reductions in aggressive incidents and staff injuries.

Student nurses’ de-escalation of patient aggression: A pretest–posttest intervention study

Background Experts recommend staff training to prevent and manage aggressive situations involving patients or their relatives. However, in many countries this subject is not covered in pre-registration nursing education. In addition, the evidence regarding its impact on practical placements remains weak. Objective This study examines the influence of an aggression management training programme for nursing students on their performance in de-escalating aggressive patients. Design Pretest–posttest within-and-between-groups design. Setting A School of Nursing in Germany. Participants Convenience sample out of six classes of nursing students at differing educational levels (10th to 28th month of nursing education, n = 78, mean age = 22). Methods In a cross-sectional and longitudinal two groups before and after design nursing students encountered two scenarios (A or B) with simulation patients. After completing the training, each student was confronted with the unknown other scenario. De-escalation experts from three German-speaking countries evaluated 156 video scenes using the De-escalating Aggressive Behaviour Scale (DABS), not knowing whether the videos had been recorded before or after the training. Mean values and statistical significance tests were computed to compare the results. Results The performance levels of students who had been trained rose significantly from 2.74 to 3.65 as measured by the DABS on a 5-point Likert scale (Wilcoxon test p < .001). The trained students managed scenario A significantly better than the untrained students (untrained 2.50, trained 3.70; Mann–Whitney- U-test p < .001,). Similar results were found for scenario B (untrained 3.01, trained 3.61; Mann–Whitney- U-test p < .001). No significant differences were found in the pretest results irrespective the students’ age or duration of previous nursing education. Conclusions Aggression management training is able to improve nursing students’ performance in de-escalating aggressive behaviour. A maturation-effect on the de-escalating performance due to general nursing education or age is unlikely.

Relationships between aggression management training, perceived selfefficacy and rural general hospital nurses’ experiences of patient aggression

Relationships between nurses’ experiences of patient aggression in the previous three months, participation in aggression management training in the previous five years and perceived self-efficacy in dealing with patient aggression are reported. Over 76 per cent of general hospital nurses employed by a rural Area Health Service in New South Wales, Australia experienced patient aggression within a three-month period. Registered Nurses and Midwifes were most affected, with over 83 per cent experiencing recent patient aggression. Most of this aggression was in the form of verbal abuse. Almost 40 per cent of nurses had not participated in aggression management training or updates in the previous five years. Approximately 70 per cent of survey respondents reported their perceived self-efficacy in dealing with patient aggression in the low to mediumhigh range. No significant association was detected between participation in aggression management training in the previous five years and the frequency of patient aggression experienced in the previous three months. Significant though very weak associations were detected between participation in aggression management training, the proportion of patient aggression experienced as verbal abuse and perceived self-efficacy in dealing with patient aggression.The findings of this and other studies highlight the need for more rigorous approaches to evaluating the effectiveness of aggression management training and undertaking patient aggression management research more broadly.

An evaluation of an aggression management training program to cope with workplace violence in the healthcare sector

Workplace violence is a major occupational hazard for healthcare workers, generating a need for effective intervention programs. The purpose of this study was to evaluate the effectiveness of an aggression management training program. The evaluation design was based on the internal referencing strategy, an unobtrusive and applicable evaluation method that rules out some major threats to internal validity without the need for a control group. On three occasions, training participants completed a questionnaire containing experimental and control variables. As hypothesized, there was a significant improvement in the experimental variables that was larger than the non-significant change in the control variable. We conclude that aggression management training may be an effective instrument in the fight against workplace violence.

Aggression prevention training for student nurses: Differential responses to training and the interaction between theory and practice

Workplace violence is of great concern to all health care professionals. Nurses are major targets for incidents of violence, with student nurses being clearly recognised as a high-risk sub-group. Training is widely advocated as the appropriate organisational response but the effects and effectiveness of training are inadequately studied. A recently completed Ph.D study used a longitudinal research design to evaluate the effects of a three-day 'aggression prevention and management training programme' on various learning domains of three cohorts of UK student nurses destined for adult, child, mental health and learning disability specialities [N=243] in their first year of nurse training. A purpose-designed questionnaire was used to collect data on knowledge, attitudes, confidence, and self-assessed competence at four time points, two before and two following the educational input. This paper focuses on the differences detected in student nurses' responses to different sections of the questionnaire, at various time points, in relation to recorded demographic variables, namely, their age, gender, destined speciality, and previous relevant training experience. It also considers the 'interaction' between theoretical preparation and clinical practice. These finding may also have wider relevance to skills training and understanding of the reality of student nurse experience in clinical settings.

Contemporary Management of Aggression in an Inner City Mental Health Service

From 2002 to mid 2003, Royal Brisbane and Women's Hospital Mental Health experienced increased patient - staff aggression and staff injury which resulted in staff conflict and recruitment difficulties. Strategies introduced to reduce the frequency and impact of aggression in the mental health service were evaluated. By mid 2003, incident data indicated increasing aggressive incidents. Based on this, an aggression management strategy was developed which included improved staff communication, new acute pharmacological treatment protocols, mandatory staff aggression management training, personal alarms and aggression risk assessment tools. Following the introduction of the strategy in early 2004, there was a reduction of 40% in aggressive incidents and a 56% reduction in staff injuries in 2005 compared to 2003 levels. A more assertive approach to tranquillisation was not associated with an increased adverse event rate for patients. A co-ordinated strategy can contain and reduce aggressive incidents in acute inpatient mental health settings. These strategies are transferable to other health settings including Emergency Departments.

Evidence Base for Practice: Reduction of Restraint and Seclusion Use During Child and Adolescent Psychiatric Inpatient Treatment

Restraint and seclusion of children has great potential for harm. Since the mid-1980s, psychiatric inpatient personnel for children and adolescents have put considerable energy in reducing the use of extreme measures of aggression management. While the use of restraints is a particular problem in the United States, aggression management and means of control in psychiatric settings is an international issue. The core question of this review was: What is the current state of the evidence supporting restraint reduction efforts with children and adolescents? Studies were reviewed and critiqued that related to programs of restraint reduction, restraint reduction methods, and aggression management. Internationally, there seems to be more emphasis on reducing coercive measures by understanding the context of their use. Thus, studies exploring staff perceptions and decisions concerning coercive measures were also examined. The evidence supporting restraint reduction methods in the United States comes mainly from case study reports of clinical sites' quality improvement projects. Consequently, a collection of studies is accumulating that supports a multi-strategy approach to restraint reduction. Limited evidence exists for aggression management measures and training in de-escalation techniques. Controversial aggression management techniques such as the use of pro re nata medication and holding continue to be used with very little support for their efficacy. Recommendations include taking a view of restraint and seclusion as emergency measures to address dangerous aggression, not interventions examined in controlled studies. As such it is suggested that sites pool data on restraint use and reduction efforts to create a database for benchmarking and studying variations among hospitals. Furthermore, attention should also be given to developing additional means for addressing aggressive behaviors.

Evaluation of the Perception of Aggression Scale (POAS) in Swedish nurses

Even though much is known about individual risk factors for institutional violence, large variations in frequency between institutions still remain unexplained. Staff attitudes have been pointed out as a possible important and explaining factor. The Perception of Aggression Scale (POAS) is a newly developed attitude inventory assessing nurses’ attitudes toward aggressive patients. The aims of this study are to evaluate the factor structure of the Swedish version of the POAS and to evaluate its discriminatory capacity in different groups of nurses. The shortened POAS was handed out to 357 nurses at 12 different psychiatric wards in Sweden. Responses were analysed with exploratory principal component factor analysis. The emerging factors were correlated in a rank-transformed multiple regression analysis to individual characteristics of each nurse. The factor analyses revealed exactly the same factor structure in this Swedish sample of nurses as in previous German and Dutch studies. When expanding the factor analysis, a three-factor solution emerged. It was also found that the factor “Aggression as a protective measure” was correlated to age and experience of aggression management training while the factor “Aggression as dysfunctional/undesirable phenomenon” was sensitive for gender. The shortened 12-item POAS contains three discrete dimensions and thus seems to be a solid tool for evaluating attitudes towards violence. Of special interest is the possibility that the factor “Aggression as a protective measure” could be sensitive to training. Further studies should correlate dimensions of staff attitudes to the occurrence of inpatient violence.

Nurses under threat: A comparison of content of 28 aggression management programs

Staff who work in the health service are now recognized as a high-risk group for assault in the workplace. Recently, professional and industrial organizations have begun to suggest appropriate curricula for training staff in aggression management. However, there is currently a plethora of aggression management training programs (AMP) available, varying both in content and in duration. In this paper, 28 programs were evaluated against 13 major content areas derived from the recommendations made from key professional and industrial organizations, and what may be today considered appropriate/ideal content areas for AMP. Information on programs available in English was sought via standard databases, the Internet, program providers, and through networking with colleagues and professional organizations. The majority of the programs reviewed covered personal safety issues for staff and patients, together with legal issues. The use of restraint, pharmacological management of aggression and seclusion were features of programs specifically addressing the needs of health care staff in mental health settings. Most programs appeared not to address the psychological and organizational costs associated with aggression in the workplace. This is surprising since the literature suggests that the effects of violence are wide and varied, including increased absenteeism and sick leave, property damage, decreased productivity, security costs, litigation, workers' compensation, reduced job satisfaction together with recruitment and retention issues. Also, few programs were based on a systematic evaluation of their outcomes. Suggestions for program development and their teaching are discussed.