An evaluation of staff training in psychological techniques for the management of patient aggression

• ? Training for staff working with violent patients is frequently recommended, sometimes implemented, but rarely objectively evaluated.
• ? In this longitudinal study 47 nurses attending a training day to learn strategies for coping with violent psychiatric patients were compared with 108 non-attending control group subjects.
• ? The rate of assaults on staff on wards taking part in the study was 31% lower after implementation of the training and wards sending a majority of staff to the training experienced a particularly significant reduction in assaults.
• ? The effectiveness of this 1-day training package is discussed.

     

Views of nursing staff on the use of physical restraint

A postal questionnaire survey was employed in regional secure and psychiatric intensive care units in England and Wales, in respect of mental health nurses' training in the use of physical restraint. The nurses' views were sought relating to their last experience of implementing the procedure. Whilst most nurses (n = 259, 96.3%) reported positive outcomes in so far that the incident was brought under control, the views of the aftereffects of the procedure were of concern and ambivalence. The literature suggests that service users did not necessarily hold the same positive views. A range of alternatives, which were consistent with the literature, was made by staff to improve intervention in the management of violence. Negative aspects relating to the use of physical restraint were also highlighted. They included procedural, injury, clinical and management issues. Some respondents also expressed concerns about the negative attitudes of their colleagues. The findings of this aspect of the survey highlights that the therapeutic value of physical restraint can only be achieved with appropriate monitoring and with emphasis on psychological intervention in the prevention and management of violence.     

Trauma for all: a pilot study of the subjective experience of physical restraint for mental health inpatients and staff in the UK

Violence and aggression is common in psychiatric inpatient units. Despite the near universal prevalence of restraint, there is very little published research on either the efficacy or the subjective effects of restraint on staff or patients. In this pilot study, semistructured interviews were given to the patients and staff involved in six untoward incidents in which the patient participant had been subject to manual physical restraint. Participants were interviewed as soon as possible after the occurrence of the incidents. The interviews asked the patient and staff participants to identify and discuss the factors that they found helpful and unhelpful during and in the immediate aftermath of these incidents. The incidents generated strong emotions for all concerned. The patients valued staff time and attention but felt that they received too little attention. Both nurses and patients discriminated between permanent and temporary staff. Patients reported feeling upset, distressed and ignored prior to the incidents and isolated and ashamed afterwards. Postincident debriefing was valued by all but was patchy for staff and rarer still for patients. Patients feared the possibility of being restrained. Half of the patients and several staff members reported that the incidents had reawakened distressing memories of previous traumatic events. Further research on the subjective effects of restraint is urgently needed.     

The Use of Physical Interventions with People with Intellectual Disabilities and Challenging Behaviour – the Experiences of Service Users and Staff Members

Background The views of both service users with intellectual disability and their support staff on the use of physical interventions are largely unknown. The research that does exist describes a largely negative pattern of responses. The present study aimed to explore the personal impact of receiving and implementing physical interventions, and also how service users and staff felt the use of such procedures impacted on each other. Method Eight service user/staff pairs were interviewed about their experiences of physical intervention within 1 week of their mutual involvement in a behavioural incident requiring restraint use. A qualitative methodology was employed to obtain views on a non‐pain compliance approach to physical intervention. Results Service user and staff experiences were intrinsically linked, highlighting the interactional nature of physical interventions. It was apparent that experiences of physical intervention were dependent on far more than the application of techniques alone. Conclusions Participants’ accounts were primarily negative. Service user and staff experiences were clearly affected by their appraisals of each other's behaviour throughout the physical intervention process.     

The manual handling of the aggressive patient: a review of the risk of injury to nurses

Staff are injured more frequently than patients during the implementation of physical interventions. In essence the application of physical interventions is a form of manual handling, where the aggressive patient is the 'load'. In the non-mental healthcare environment, manual handling contributes to a large chunk of work-related musculoskeletal disorders. Applying physical interventions against an agitated and aggressive human load is a risk factor for injuries being sustained. This paper discusses physical interventions as a manual handling procedure as a possible explanation of injuries sustained to nursing staff from being in a team applying physical interventions. Possible strategies to reduce the risk of developing musculoskeletal disorders from physical interventions are discussed.     

Perspectives on the experience of being physically restrained: an integrative review of the qualitative literature

Publications providing information on the safe use of physical restraints, guidelines for restraint use, and journal articles on the care of mental health patients are frequently devoid of information regarding patients' perspectives on physical restraint. As physical restraint is a common procedure in many settings, the purpose of this review is to examine and summarize the qualitative literature on patients' perspectives on being physically restrained, from 1966 through to 2009. A formal integrative review of existing qualitative literature on patients' perspectives of physical restraint was conducted. Studies were critiqued, evaluated for their strength, and analysed for key themes and meanings. Twelve studies were ultimately identified and included in the review. Four themes emerged from the review, including negative psychological impact, retraumatization, perceptions of unethical practices, and the broken spirit. While little qualitative research on patients' perceptions of physical restraint exists, findings within the current literature reveal serious implications for patients and nurses alike. Additional research into physical restraint implications for the patient-nurse dyad is needed, and nurses should approach the use of physical restraint with caution and awareness of their potential psychological impact.     

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 impact of psychosocial training on staff attitudes towards people living with dementia: A systematic review

Background

As the prevalence of dementia increases, the need for appropriately trained and skilled care teams also increases. Staff attitudes towards people living with dementia have a significant impact on caregiving behaviours and staff and resident outcomes. Training within care settings is a potential way of improving staff attitudes towards residents in their care.

Objectives

This review aimed to (i) assess the effectiveness of psychosocial training in improving care staff attitudes towards dementia; and (ii) examine the content and focus of training.

Method

The review was conducted following PRISMA guidance and the protocol was registered on PROSPERO prior to conducting the review. A comprehensive search of peer-reviewed literature was undertaken using CINAHL, Medline and PsycINFO from inception to March 2021. All papers were evaluated using a quality appraisal tool.

Results

Ten studies met inclusion criteria and were of variable quality. However, six studies found significant improvements in staff attitudes towards dementia following staff training. The studies varied in terms of training focus and included behavioural, communication and cognitive-based approaches.

Conclusions

Staff training could be an effective method of improving staff attitudes towards dementia in care settings. Further research adopting high-quality randomised controlled designs to further explore staff attitudes following psychosocial training would make a valuable contribution to the literature base.     

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.
Implications: 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.     

A randomized controlled trial to assess the impact of an Admission Service on patient and staff satisfaction

Norton‐Westwood D, Robertson‐Malt S, Anderson R. International Journal of Nursing Practice 2010; 16 : 461–471
A randomized controlled trial to assess the impact of an Admission Service on patient and staff satisfaction This study aims to assess the benefits of an Admission Service (AS) wherein the nurse, when fluent in the language spoken by the patient (Arabic), improves the accuracy and efficiency of acquiring key assessment data needed to guide nursing care. Patients' satisfaction with their hospital experience begins formulating from their time of admission. Dissatisfaction is frequently reported in areas requiring careful, skilled communication such as obtaining emotional support and family participation and education. Over a 3‐month study recruitment, 314 patients were randomly assigned to be admitted either through the AS (n = 150) or to the unit via the standard admission process (n = 164). The AS improved the efficiency of admission time by > 150%. The nurse's assessment of their quality of admission was also improved: 76 vs. 26 nurses rated their quality of admission as ‘very good’ when assisted by the AS compared with standard admission to the unit.     

An evaluation of staff and patient views of and strategies employed to manage inpatient aggression and violence on one mental health unit: a pluralistic design

Following an initial springboard study, a further more extensive piece of research was conducted to identify and evaluate approaches used to manage patient aggression and violence on three acute mental health wards. Data were gathered using an incident form, a questionnaire and interviews. The views of patients (n = 80), nurses (n = 72) and medical staff (n = 10) were explored. Findings revealed a clear distinction between the way staff and patients view both the problem and the response. Patients' view present staff approaches as 'controlling' and believe that environmental and poor communication factors underpin aggressive behaviour. Staff, conversely, attribute aggressive behaviour to internal patient and external factors, which may explain the reason for approaches used. A strong correlation was found between type of patient aggression and response (r = 0.36, P < 0.000) and a high percentage of incidents reported were of an aggressive, as opposed to violent, nature. For example 70% of incidents involved verbal abuse or threat. Despite this, 47% (n = 103) of approaches incorporated the use of medication, restraint or seclusion. These are commonly referred to as traditional methods. Patients clearly view this controlling style as a part of the problem and an emphasis upon control and symptom reduction may be inappropriate given the type of aggression encountered. Key issues were further analysed using an internal, external and situational model, each of which endeavour to explain reasons for patient aggression from different perspectives. It is this emphasis upon sole perspectives that may both contribute to and result in the use of a limited number of management approaches adopted in practice. The integration of all three models to examine the complex nature of patient aggression and violence from a variety of perspectives may be the way forward. As a result, approaches to deal with this problem could be more meaningful and subsequently effective.     

Patient and visitor violence in the general hospital,occurrence, staff interventions and consequences: a cross‐sectional survey

Aim. This study focuses on the experience of healthcare staff with regard to patient and visitor violence in a general hospital. The occurrence of patient and visitor violence, staffs’ interventions and the consequences of violence for different professions are investigated. Background. There is a lack of studies describing the factors influencing the occurrence of patient and visitor violence, intervention strategies and consequences. Existing studies often focus on nurses’ experiences and single interactive factors between staff and patients/visitors involved. Design. A cross‐sectional survey. Method. The survey was conducted in 2007 including 2495 staff working on different wards in a Swiss university general hospital. The questionnaire used was the Survey of Violence Experienced by Staff German Version‐Revised. Findings. Half of the staff experienced patient and visitor violence in the past 12 months and 11% in the past week. The age of the staff and the length of experience in their present workplace influenced the exposure to patient and visitor violence. Violence occurred mainly when staff carried out tasks involving close personal contact. Only 16% of the staff was trained in aggression management. The feeling of confidence in managing patient and visitor violence depended significantly on the organizational attitude towards violence. The principal interventions used were calming and informative discussion. Conclusion. To prevent patient and visitor violence and improve management strategies, training which focuses on communication skills, which is specific to the professional context and which emphasizes patient centeredness, need to be designed and implemented. A strong organizational commitment is imperative to reduce violence.     

Cancer patient and staff ratings of the importance of caring behaviours and their relations to patient anxiety and depression

Patient and staff ratings of the importance of caring behaviours (Caring Assessment Instrument, CARE-Q) were studied and related to ratings of patient levels of anxiety and depression (Hospital Anxiety and Depression Scale) in 53 cancer patient–staff dyads. Both groups perceived anticipatory and comforting behaviours to be among the three most important. Patients considered staff explanation and facilitation as well as anticipation to be more important than did staff. Staff rated accessibility and comforting as more important than did patients. Patient and staff ratings of the importance of staff accessibility were negatively correlated. Thus, patient and staff did not agree strongly on the importance of several types of caring behaviours. Neither patient nor staff ratings of the importance of caring behaviours were associated with their ratings of the levels of anxiety or depression of specific patients. The results suggest that patient–staff communication requires specific knowledge and skills to make staff accurately judge what is important in making patients feel cared for.     

Staff attitudes towards aggression in health care: a review of the literature

The aim of this literature review was to explore the attitudes of health care workers towards inpatient aggression and to analyse the extent to which attitudes, as defined from a theoretical point of view, were addressed in the selected studies. Databases from 1980 up to the present were searched, and a content analysis was done on the items of the selected studies. The concepts 'cognition' and 'attitude' from the framework of 'The Theory of Reasoned Action' served as categories. The self-report questionnaire was the most common instrument used and three instruments specifically designed to measure attitudes were found. These instruments lacked profound validity testing. From a total of 74 items, two thirds focussed on cognitions and only a quarter really addressed attitudes towards aggression. Research was particularly concerned with the cognitions that nurses had about aggression, and attitudes were studied only to a limited extent. Researchers used different instruments, which makes it difficult to compare results across settings.