De-escalating aggression and violence in the mental health setting

Aggressive and violent incidents in the health-care setting are increasing phenomena around the world. The evidence from current literature suggests that changes in health-care access, nursing staff shortages and patient acuity are some of the possible causes. De-escalation is a valuable intervention that can be used by nurses to help counter the growing problems of aggression and violence. The de-escalation project, discussed in the present paper, aimed to explore de-escalation as an important therapeutic process and is an event of considerable potential in the management of aggression and violence. While de-escalation is not a new tool, particularly in the mental health-care setting, an educative programme aimed at renewing nurses' knowledge and skills in de-escalation is a timely project. The final de-escalation kit included a large glossy poster, a nursing staff survey, an in-service education session and a literature-based discussion paper. The de-escalation kit can be of considerable benefit to those nurses who are transient within the workplace, such as casual and agency nurses.     

The role of interpersonal style in aggression and its containment in a forensic mental health setting: A correlational and pseudoprospective study of patients and nursing staff

Inpatient aggression on mental health wards is common and staff–patient interactions are frequently reported antecedents to aggression. However, relatively little is known about the precise relationship between aggression and these interactions, or their relationships with aggression and staff containment responses such as restraint and seclusion. This study aimed to determine the roles of anger and interpersonal style among mental health nurses and between nurses and patients in the occurrence of aggression and its containment. A correlational, pseudoprospective study design was employed. n = 85 inpatients and n = 65 nurses were recruited from adult, low‐ and medium‐secure wards of a secure forensic mental health service. Participants completed validated self‐report anger and transactional interpersonal style measures. Inpatient aggression and containment incident data for a 3‐month follow‐up period were extracted from clinical records. Dyadic nurse–patient relationships were anticomplementary. Patients' self‐reported anger and staff‐rated hostile interpersonal style were significantly positively correlated; staff self‐reported anger and patient‐rated dominant interpersonal style were also positively correlated. Patient anger predicted aggression and their interpersonal style predicted being subject to containment in the form of restraint and seclusion. There were no statistically significant differences identified on measures between staff who were and were not involved in containment. More targeted intervention for patients' anger may have a positive impact on interpersonal style and lead to the reduction of incidents. Staff education and skills training programmes should emphasize the importance of interpersonal styles which could help to promote and enhance positive interactions.     

An exploratory account of registered nurses' experience of patient aggression in both mental health and general nursing settings

Until relatively recently, aggression and violence in nursing has been an area of little discussion (Poster & Ryan 1993). Today, concerns are rising about escalating levels of violence towards nurses (Wykes 1994, Whittington 1997). In response, this paper explores registered nurses' experiences of patient aggression encountered in the acute inpatient general and mental health settings. Critical incidents from registered nurses in both areas are examined and analyzed in relation to existing literature. The aim of the research is to ascertain if differences exist or similarities prevail. Findings reveal that the two areas have similar problems in terms of types of aggression. Verbal and 'minor' types of aggression are the most problematic. Also, the 'biomedical model' of care is evident in both settings and possibly underpins chosen approaches to aggression management. The repeated use of chemical and physical restraint is apparent. The main comparison identified between the two groups relates to nursing control over situations involving violent patients. Mental health nurses seem to consistently take control of aggressive situations whilst general nurses tend to rely more heavily upon the input of others (medical staff, mental health teams and the police) when intervening. These two nursing specialties therefore have much to learn from each other in terms of nursing experience and possible future approaches to the management of aggressive patients.     

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.     

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.     

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.     

The effectiveness of chemical restraint in managing acute agitation and aggression: A systematic review of randomized controlled trials

One approach to manage people with behaviours of concern including agitated or aggressive behaviours in health care settings is through the use of fast‐acting medication, called chemical restraint. Such management often needs to be delivered in crisis situations to patients who are at risk of harm to themselves or others. This paper summarizes the available evidence on the effectiveness and safety of chemical restraint from 21 randomized controlled trials (RCTs) involving 3788 patients. The RCTs were of moderate to high quality and were conducted in pre‐hospital, hospital emergency department, or ward settings. Drugs used in chemical restraint included olanzapine, haloperidol, droperidol, risperidol, flunitrazepam, midazolam, promethazine, ziprasidone, sodium valproate, or lorazepam. There was limited comparability between studies in drug choice, combination, dose, method of administration (oral, intramuscular, or intravenous drip), or timing of repeat administrations. There were 31 outcome measures, which were inconsistently reported. They included subjective measures of behaviours, direct measures of treatment effect (time to calm; time to sleep), indirect measures of agitation (staff or patient injuries, duration of agitative or aggressive episodes, subsequent violent episodes), and adverse events. The most common were time to calm and adverse events. There was little clarity about the superiority of any chemical method of managing behaviours of concern exhibited by patients in Emergency Departments or acute mental health settings. Not only is more targeted research essential, but best practice recommendations for such situations requires integrating expert input into the current evidence base.     

Violence and aggression in the emergency department

Objective

To investigate the characteristics of incidents of aggression and violence directed towards staff in an urban UK emergency department.

Methods

A retrospective review of incident report forms submitted over a 1 year period that collected data pertaining to the characteristics of assailants, the outcome of incidents, and the presence of possible contributory factors.

Results

A total of 218 incident reports were reviewed. It was found that the majority of assailants were patients, most were male, and the median age was 32 years. Assailants were more likely to live in deprived areas than other patients and repeat offenders committed 45 of the incidents reported during the study period. The incident report indicated that staff thought the assailant was under the influence of alcohol on 114 occasions. Incidents in which the assailant was documented to have expressed suicidal ideation or had been referred to the psychiatric services were significantly more likely to describe physical violence, as were those incidents in which the assailant was female.

Conclusion

Departments should seek to monitor individuals responsible for episodes of violence and aggression in order to detect repeat offenders. A prospective study comprising post‐incident reviews may provide a valuable insight into the causes of violence and aggression.     

Developing a non-aversive intervention strategy in the management of aggression and violence for people with learning disabilities using natural therapeutic holding

This paper builds upon a previous piece of research regarding the development of 'natural therapeutic holding' as a non-aversive alternative to control and restraint (C and R) in managing aggression and violence in people with learning disabilities. This paper represents aspects of an ongoing programme of research and explains the aims and values which underpin natural therapeutic holding by describing the theory, aims, values and practical application. The concepts of individual risk management and pro-active intervention strategies are discussed with illustrations of practical application given by means of a case study. The case study shows that over a relatively short period of time, an individual with severe learning disabilities who is aggressive and violent, learns alternative coping strategies to aggression and violence through the application of natural therapeutic holding. The article concludes that natural therapeutic holding is a very effective intervention strategy in the management of violence in people with learning disabilities from two perspectives: (a) it provides staff with safe, professional and ethical skills with which they can manage aggressive and violent clients and (b) as a therapy, natural therapeutic holding gives clients the opportunity to learn coping strategies which are more effective than violence.     

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.     

Reducing Use of Physical Restraint: A Pilot Study Investigating a Relationship-Based Crisis Prevention Curriculum

The use of physical restraint in residential treatment programs continues to be a topic of debate. Yet, there is a scarcity of empirical research on effective methods for reducing both the need and the use of physical restraint. Without such evidence, there is no clear direction on how to improve staff practices when working with students experiencing emotional and behavioral challenges. Consequently, it has been difficult for programs to develop clear, consistent, and definitive efforts to reduce restraint practices and eliminate unnecessary restraint. In an effort to improve program practices, we designed and piloted a relationship-based crisis prevention curriculum. In this article we discuss the pilot study and briefly outline curriculum features. Pilot study results reveal a statistically significant reduction in restraint, a shift in attitudes about prevention and need for restraint, and a positive trend in staff preparation. Additionally, the social validity of the curriculum and future directions for practice and research are discussed.     

The shoulder: taking the strain during restraint

The decision to use or utilize physical intervention techniques is a contentious one. There has been much discussion on the complex legal and ethical dimensions framing the use of force. The risk of injury has also been considered in detail, but almost all of the published work has focused on restraint asphyxia, the prone restraint hold and the use of particular pain compliance techniques such as the wrist flexion hold. This paper focuses on the structure and function of the shoulder and examines how physical interventions and a variety of risk factors can threaten its physical integrity. This paper is for practitioners such as training commissioners, trainers, frontline staff and investigators or regulators who have to make considered determinations on the potential immediate physical impact of a variety of holds and escape manoeuvres. Sound risk assessment must be premised on a sound understanding of anatomy and physiology.     

Natural therapeutic holding: a non-aversive alternative to the use of control and restraint in the management of violence for people with learning disabilities

For at least the last 10 years, control and restraint (C&R) has gained increased popularity amongst nurses as a safe, professional and legal means to manage violence in health care settings. However, during this period there has been an increased momentum to find non-aversive management strategies for people with learning disabilities and there has been frequent debate on the abolition of practices which do not achieve this. More recently, the main criticisms of C&R have been the professional and ethical objections that the techniques used inflict some degree of pain or discomfort to the client, and the fact that it remains a reactive strategy with no theoretical framework for professional practice. On this basis, alternatives should be sought which seek to address these issues. This paper outlines the development of natural therapeutic holding, an approach which is non-aversive and which provides a theoretical structure for professionals to base their practice on in order to develop clear therapeutic goals for the client. Initial findings within a small community residential service for people with learning disabilities indicate that natural therapeutic holding was a preferred method of intervention strategy by staff, proving as effective as C&R in the management of violent incidents, with interventions being much shorter in duration and non-aversive in nature.     

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.     

The nurse's role in patient-centred medicines management

Nurses in all care settings are crucial to the effective delivery of medicines management. This paper argues that adopting a collaborative approach will help patients get the most out of their medication and reduce non-compliance. The 'concordance' approach recognises partnership rather than directorship, and is based on arriving at shared agreements.     

The practice nurse's role in the management of epilepsy

Epilepsy is a serious and common neurological condition of which the medical, psychological and social implications are far-reaching. This article aims to discuss the practice nurse's role in responding to the needs of clients with epilepsy. This is explored from a primary health care perspective, focusing on nursing interventions and implications for practice. The potential exists for community nursing intervention to improve quality of life for clients through responsive service provision and by challenging the inequality that appears to exist with regard to it. The available research is overtly pharmacological in origin and nursing research in this field is extremely sparse.