The effect of a training course in aggression management on mental health nurses' perceptions of aggression: a cluster randomised controlled trial

Nurses' attitudes towards patient aggression may influence their behaviour towards patients. Thus, their enhanced capacity to cope with aggressive patients may nurture more positive attitudes and alleviate adverse feelings emanating from patient aggression. This cluster randomised controlled trial conducted on six psychiatric wards tested the hypotheses that a 5 day training course in aggression management would positively influence the following outcome measures: Nurses' perception and tolerance towards patient aggression and resultant adverse feelings. A repeated measures design was employed to monitor change. No effect was found. The short time frame between the training course and the follow up measurement or non-responsiveness of the measurement instruments may explain this finding.     

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

Aggression in healthcare systems poses a major problem for nurses because they are the most susceptible to suffer violence. Studies demonstrate that attitudes of nurses influence their behaviour regarding aggression and violence. Training programmes can positively change nurses' attitudes. This quasi-experimental study aimed to examine the effects of a systematic training course in aggression management on mental health nurses' attitudes about the reasons for patients' aggression and on its management. Sixty-three nurses (29 in the intervention and 34 in the control group) participated in this quasi-experimental pre-test and post-test study. The attitude of the participants of a training course was recorded by the German version of the Management of Aggression and Violence Attitude Scale (MAVAS). No significant attitude changes occurred in the intervention group at post-test. It is concluded that trainings intending to influence attitudes regarding the reason for patient aggression should consider the impact of the pedagogical quality of the training course, organizational support, and the user's perception. Moreover, it remains questionable to what extent a single instrument of measurement can record attitude changes.     

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.     

Causes and management of patient aggression and violence: staff and patient perspectives

Aim.  This paper reports a study of staff and patient perspectives on the causes of patient aggression and the way it is managed.
Background.  The incidence of aggression in healthcare is reportedly on the increase, and concerns about the management of this problem are growing.
Method.  A convenience sample of 80 patients and 82 nurses from three inpatient mental healthcare wards were surveyed using The Management of Aggression and Violence Attitude Scale. A further five patients and five nurses from the same sample participated in a number of follow-up interviews.
Results.  Patients perceived environmental conditions and poor communication to be a significant precursor of aggressive behaviour. Nurses, in comparison, viewed the patients' mental illnesses to be the main reason for aggression, although the negative impact of the inpatient environment was recognized. From interview responses, it was evident that both sets of respondents were dissatisfied with a restrictive and under-resourced provision that leads to interpersonal tensions.
Conclusion.  There are differences between the views of staff and patients about reasons for aggression and its management. Future approaches therefore need to be developed that address these opposing views. For example, training in the use of fundamental therapeutic communication skills was advocated by patients, whilst the need for greater attention to organizational deficits was advocated by nurses. A move away from reliance on the use of medication was also felt to be necessary. Evaluation of local needs and practices must be an integral part of this process.     

Evaluating a management of aggression unit for student nurses

BACKGROUND: Workplace violence is acknowledged as a major problem in health care settings and affects staff morale, recruitment, retention and direct health care budgets. Staff training is advocated as the appropriate managerial response, but identifying appropriate training and trainers is difficult and there is little published evidence of training effectiveness. Student nurses are frequent targets of aggression but are less likely to receive specific training. AIMS: The study considered the application of a model of learning to a 3-day learning unit for diploma-level student nurses on the "prevention and management of aggression". It aimed to measure student outcomes of the unit and gain information about more general issues in evaluating training effectiveness. METHODS: A repeated measures longitudinal design was used to obtain data from three cohorts of student nurses (3 x 80 approximately) at four time points over an 8-month period. A questionnaire was administered twice before the unit, at its conclusion and approximately 3 months afterwards, following two clinical placements. RESULTS: Statistically significant changes were demonstrated in a number of areas, including number of risk factors identified, and five "factors" identified from the questionnaire statements. STUDY LIMITATIONS: The results refer to one course for student nurses that had many common elements with popular training courses for qualified staff, including inter-personal and breakaway skills. However, restraint skills were not included. CONCLUSIONS: It is possible to provide training that produces desirable, statistically demonstrable and durable change in knowledge, behaviour, attitudes and confidence using a rigorous longitudinal evaluation research design.     

Limit-setting and decision-making in the management of aggression

BACKGROUND: Several published research studies have suggested that inpatient aggression against nursing staff may be directly precipitated by common nurse-patient interactions. This study sought to examine the structure of nurses' judgements in situations of conflict. METHOD: Seventy practising United Kingdom psychiatric nurses were presented with a number of conflict scenarios and were asked to rate a range of intervention options for each scenario according to how appropriate they perceived those interventions to be. Their responses were analysed using multidimensional scaling techniques. RESULTS: The results suggest that issues associated with limit setting and autonomy were perceived as most important by the nurses and that these issues are most likely to lead to disagreements in judgement between nurses of different status. Nurses of higher grades (levels) showed a significantly greater preference for respectful and autonomy-confirming interventions than their more junior nurses. These results have training and policy implications and further research should examine the effects of such nursing judgements on patient care.     

Prevalence and predictors of verbal aggression in a secure mental health service: Use of the HCR‐20

Despite evidence about the negative effects of verbal aggression in mental health wards there is little research about its prevalence or about the factors that predict the behaviour among inpatients. This study aimed to determine the prevalence of verbal aggression in a secure mental health service, and to examine the relationship of verbal aggression with risk factors for aggression in the risk assessment tool HCR‐20 in order to establish whether, and with which factors, the behaviour can be predicted. Verbal aggression was measured using the Overt Aggression Scale (OAS) over a 3‐month period across a heterogeneous patient group (n = 613). Over half the patients (n = 341, 56%) engaged in 1594 incidents of verbal aggression. The HCR‐20 total, clinical, and risk management subscale scores predicted verbal aggression, though effect sizes were not large. Item‐outcome analysis revealed that impulsivity, negative attitudes, and non‐compliance with medication were the best predictors of verbal aggression and, therefore, should be targeted for intervention. There are key synergies between factors predicting verbal aggression and the core mental health nursing role. Nurses, therefore, are in a prime position to develop and implement interventions that may reduce verbal aggression in mental health inpatients.     

精神科护士的自我保护

本文通过对我院1995年11月—1996年11月受到精神病人攻击的76名护士的情况进行回顾性总结调查,发现:男女病人攻击护士的方式不完全一样,男女病人24小时之内以5Pm—1Am发生攻击行为最多,与护士的技巧、护龄长短、责任心等有关系;并且精神病人的攻击行为是可以预测的,通过加强保护措施护士的受伤也是可以避免的。     

Human dignity and professional reputation under threat: Iranian Nurses' experiences of workplace violence

Workplace violence against nurses is a challenging problem in both developed and developing countries. Because the concept of violence bears some cultural load, nurses' understanding is region‐specific. This study explores Iranian nurses' perceptions of workplace violence. Using qualitative content analysis, 22 registered nurses underwent unstructured, in‐depth interviews. The main themes of threats to human dignity and professional reputation emerged, plus four categories: physical violence, psychological violence, honor insults, and ethnic‐religious insults. The term "honor insults," as a unique finding, was used instead of "sexual harassment." These findings may help to redefine workplace violence based on cultural background, design strategies for supporting nurses, and prevent and manage such violence.     

The nurse's role in the management of aggression

Although research into the phenomenon of aggression within psychiatric inpatient settings has established a strong casual link with mental illness, there is widespread agreement that diagnostic or demographic characteristics cannot accurately predict such behaviours. In addition, studies have consistently failed to establish how nursing management responses influence the course of aggression within these environments. Therefore, an assumption can be made that specific contextual factors are significant, and that management responses have an effect on outcomes. This review examines the nurses' impact on inpatient aggression and how management strategies affect the therapeutic value of intervention.     

神经外科护士实施层级培训管理的效果

目的 探讨在神经外科进行层级培训的方法及效果,以提高护理队伍的整体素质.方法 采用层级培训管理模式,对20名护理人员采用教师分层级,将培训贯彻于日常的护理工作中,理论联系实践,注重工作过程中的培训,定期进行效果评估和反馈.结果 本组护士培训后考核成绩及护理工作胜任力与培训前比较明显提高(P<0.001).结论 层级培训管理模式可有效提高护理人员的综合素质和护理工作胜任力,确保护理安全.     

Nursing management of aggression in a Singapore emergency department: A qualitative study

In Singapore, anecdotal evidence suggests that nurses are concerned about managing aggressive incidents in the emergency department. In this study, registered nurses' perceptions of managing aggressive patients in an emergency department were explored. Ten registered nurses from the emergency department of an acute public hospital in Singapore were interviewed. Four overarching themes emerged from the thematic analysis: (i) impact of aggressive patients on nurses; (ii) nursing assessment of aggressive behaviors; (iii) nursing management of aggressive behaviors; and (iv) organizational support and responsiveness. Further research is required to better support nurses to deliver optimal care for aggressive patients and achieve positive and effective outcomes.     

The perception of aggression by nurses: psychometric scale testing and derivation of a short instrument

Patient aggression is a serious problem in psychiatric nursing. Nurses' attitudes towards aggression have been identified as mediating the choice of nursing interventions. To date, investigations are lacking which elucidate the stability of one of the few scales for measuring the attitude of aggression. This study aimed to investigate the test-retest stability of the Perception of Aggression Scale and to derive a shortened version. In order to test the reliability of the Perception of Aggression Scale items, three groups of psychiatric nurses were requested to fill in the Perception of Aggression Scale twice (30 student nurses after 4 days, 32 qualified nurses after 14 days and 36 qualified nurses after 70 days). We derived the shortened version from an independent data set obtained from 729 psychiatry nurses using principal component analysis, aiming to maximize parsimony and Cronbach's alpha. Amongst competing short versions, we selected those with the highest reliability at 70 or 14 day retest. A scale using 12 of the original 32 items was derived yielding alphas of r = 0.69 and r = 0.67 for the two POAS factors with retest reliabilities of r = 0.76 and r = 0.77. The shortened scale offers a practical and viable alternative to the longer version.     

Evaluating the impact of an electronic application of the Dynamic Appraisal of Situational Aggression with an embedded Aggression Prevention Protocol on aggression and restrictive interventions on a forensic mental health unit

Risk assessment is a pre‐requisite for violence prevention in mental health settings. Extant research concerning risk assessment and nursing intervention is limited and has focused on the predictive validity of various risk assessment approaches and instruments, with few attempts to elucidate and test interventions that might prevent aggression, and reduce reliance on coercive interventions. The integration of risk assessment and violence prevention strategies has been neglected. The aim of this feasibility study was to test a novel Aggression Prevention Protocol designed to prioritize the instigation of less restrictive interventions on an acute forensic mental health unit for female patients. A prospective quasi‐experimental study was designed to test an Aggression Prevention Protocol, linked to an electronic application of the Dynamic Appraisal of Situational Aggression (DASA). Following introduction of the DASA and Aggression Prevention Protocol, there were reductions in verbal aggression, administration of Pro Re Nata medication, the rate of seclusion, and physical and mechanical restraint. There was also an increase in documented nursing interventions. Overall, these results support further testing of the electronic application of the DASA and the Aggression Prevention Protocol.     

The effectiveness of two interventions in the management of patient violence in acute mental inpatient settings: report on a pilot study

Systematic risk assessment and training courses have been suggested as interventions to deal with patient violence in psychiatric institutions. A dual centre prospective feasibility study was conducted on two Swiss psychiatric admission wards to test the hypothesis that such interventions will reduce the frequency and severity of violent events and coercion. A systematic aggression risk assessment, in combination with a standardized training course in aggression management was administered and the frequency and severity of aggressive incidents and the frequency of coercive measures were registered. The incidence rates of aggressive incidents and attacks showed no significant reduction from the baseline through risk prediction and staff training, but the drop in coercive measures was highly significant. A 'ward effect' was detected with one ward showing a decline in attacks with unchanged incidence rates of coercion and the other ward showing the opposite. The severity of the incidents remained unchanged whilst the subjective severity declined after the training course. We conclude that a systematic risk assessment and a training course may assist in reducing the incidence rate of coercive measures on psychiatric acute admission wards. Further testing of the interventions is necessary to measure the effect of the training alone and to counteract 'ward effects'.     

Non-somatic effects of patient aggression on nurses: a systematic review

AIM: This paper describes a systematic review of the predominant non-somatic effects of patient assault on nurses. Background. Patient aggression towards nurses is a longstanding problem in most nursing domains. Although reports on the consequences of physical aggression are more numerous, the non-physical effects create much suffering. METHOD: A systematic review of literature from 1983 to May 2003 was conducted using the Medline, CINAHL, PsychINFO and PSYINDEX databases. Articles from international journals in English or German and reporting at least three non-somatic responses to patient aggression were included. FINDINGS: The electronic search produced 6616 articles. After application of the inclusion and exclusion criteria, 25 texts from eight countries and four domains of nursing remained. Twenty-eight main effects were found, and these were categorized using a system suggested by Lanza and including bio-physiological, emotional, cognitive, and social dimensions. The predominant responses were anger, fear or anxiety, post-traumatic stress disorder symptoms, guilt, self-blame, and shame. These main effects occurred across most countries and nursing domains. CONCLUSION: Despite differing countries, cultures, research designs and settings, nurses' responses to patient aggression are similar. Standardized questionnaires could help improve estimations of the real prevalence of non-somatic effects. Given the suffering caused by non-somatic effects, research should be aimed at preventing patient aggression and at developing better ways to prepare nurses to cope with this problem.