Aggression in Psychiatric Ward

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Violence & Aggression

Running Head: AGGRESSION IN PSYCHIATRIC WARDS

Current issues in managing violence and aggression in acute psychiatric ward setting

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Current issues in managing violence and aggression in acute psychiatric ward setting

Abstract

This paper researches the current issues, management and developments related to violence and aggression in psychiatric ward. With the help of the literature review and а series of textual and personal observation I have tried to explore and examine the issues which arose during а clinical survey of an acute psychiatric admission ward. The problems of nurses (staff) and as well as patient’s troubles, methodologies to rectify those issues have also been discussed along with а detailed literature review. It also tried to review critically the main objectives, aims and concerns of psychiatric ward.


Table of Contents


CHAPTER 1: INTRODUCTION

Background

Violent incidents on psychiatric wards have long been acknowledged to be an important topic for research, both for psychiatric nurses and for other professions. The subject is important for а number of reasons. First and foremost of these is the potential for violence, harm and injury to nurses (staff) or to other patients. However, the study of violent incidents has touched upon many other areas which are of high importance to the practice of psychiatric ward setting, namely nurse-patient interaction, ward atmosphere, and the issue of control versus care, among others.

However, the focus of this paper is violent incident instrumentation, or how violent incidents are defined, counted and measured for the purposes of research. Not а great deal has been written about this, although it is а crucial issue for all research that seeks to ascertain the causes and consequences of violent incidents. Two recent reviews of violent incident instrumentation have made some progress by bringing together for consideration and comparison some of the existing literature and instrumentation (Bech P. 1994. p. 290–302.). However, I believe that these reviews have not fully described the problems in this area, and have failed to uncover serious flaws in the currently used research instruments. Some significant progress has been made by (Bech P. 1994. p. 390–395.) with their use of video cameras, but although this shows а way forward, the method has limitations of its own. I will therefore review existing methods of counting and rating violent incidents, before passing on to discuss in detail the issues that arise.

Scales for inclusion in this paper will be identified during the course of reviewing the literature on violent incidents on psychiatric wards. Literature searches for empirical studies were conducted using PSYCHLIT and CINAHL. References to the instruments used in those studies were then obtained. The Scale for the Assessment of Aggressive and Agitated Behaviours (SAAB) (Bjrkly S. 1995. p. 475–502.) was excluded, as no example copy exists in the literature and it has not been used elsewhere. On the basis of the published information, it does not appear to have any advantages over other, more readily available scales  quantify frequency and severity of aggressive incidents are needed (Bech, 1994; Bowers, 1999). Instruments for measuring aggressive behavior of psychiatric patients can be roughly divided into self-rating aggression scales and observer aggression scales (Bech, 1994). The Aggression Questionnaire of (Buss, 1992, p. 452–459) is an example of а self-rating instrument. Referring to self-rating aggression scales in general, it has been noted that major problems in obtaining self-report measures from psychotic patients complicates this approach to prediction research. On а related note, (Yudofsky, 1986, p. 35–39.) suggested “many patients are not angry between aggressive episodes, and do not reliably recall or admit to past violent events” (p. 35).         For these and other similar reasons, many studies on the prevalence and prevention of inpatient aggression have relied on information provided by others, usually (nursing) staff members (Nijman, 1999) Examples of staff observation aggression scales are the Overt Aggression Scale (Yudofsky, 1986, p. 39–45.) and the Modified version of this instrument (Kay, 1988, p. 539–546.) the Staff Observation Aggression Scale (Palmstierna and Wistedt, 1987) and its revised version (Nijman, 1999), the Report Form for Aggressive Episodes  (Bjorkly, 1996) and the recently developed Attempted and Actual Assault Scale (Bowers, 2002).

Depending on the instrument(s) used, and the type and location of wards investigated, the reported annual aggression frequencies per psychiatric patient vary considerably across studies (Nijman, 1997, p. 106–114) Using the SOAS, for instance, Palmstierna and colleagues found about 13 incidents per patient per year on а Swedish acute admission ward (Palmstierna and Wistedt, 1995; Palmstierna, 1991), whereas in the Netherlands about 20 incidents per admission bed per year were found on highly similar wards (Nijman, 1997, 1999). About 10 percent of SOAS-reports concern incidents that have physical consequences (e.g., pain, bruises) for victims. In particular, involuntarily admitted psychiatric patients appear to have а high likelihood of behaving aggressively during psychiatric hospitalization (Nijman, 2002, p. 198–200.)

Since most of the aforementioned staff observation scales concern ‘incident-based’ measurements (i.e., they are used to record discrete episodes of aggressive behaviour), they need to be used for prolonged periods of time to obtain а reliable picture of the prevalence of aggressive behaviour on а psychiatric ward. To be able to gain insight into staff members’ day-to-day experiences with aggression more quickly, Oud proposed а 15–item questionnaire [2001], on which staff members can rate which forms of aggression they have experienced themselves (in cases of interpersonal conflict behaviour), or witnessed (in cases of self-harming or property-destroying behaviour) during the last year.

Since this rapid and rather easy method is likely to produce estimates – rather than exact aggression frequencies – it was decided to name the instrument “Perceptions of Prevalence of Aggression Scale” (POPAS), and it is to completely anonymous. а sixteenth item was added to the POPAS, in which respondents were asked to disclose the number of days they missed from work in relation to workplace violence. (Morrison, 1993a, p.51-64.) In this way, POPAS assessments may be helpful in gathering this rather delicate, but essential, management information, in а short period of time.

Purpose of the Study

In the present study, the internal consistency of this newly developed scale was investigated, and psychiatric nurses’ experiences with aggression explored. Apart from that, the associations between а number of characteristics of the respondents (i.e., gender, age, education, and type of ward), and experiences with aggression were also investigated in an exploratory manner. (Overall, 1962, p. 799-812)

Some expectations, however, existed about potential associations beforehand.

More specifically, it was assumed that:

1) Female and young staff members might experience more sexual harassment during their work;

2) Qualified nurses, and nurses who had followed Control and Restraint (C&R) trainings might have а lower chance of experiencing (severe) aggression.

These points are important as the nurses are supposed to be more skilled at preventing or dealing with aggression (Carmel, 1989 p. 41–46. Staff members working exclusively with involuntarily admitted patients might experience more aggression, since aggression seems to be more prevalent in involuntarily hospitalized samples (Nijman, 2002, p. 198–200.)


CHAPTER 2: LITERATURE REVIEW

Aggression

        Aggression is а frequent and problematic aspect of psychiatric inpatient treatment (Haller, 1988 p. 174–179). Previous research has shown that many of the same demographic characteristics associated with aggression in psychiatric inpatients are associated with aggression in the general population (Hodgkinson, 1984, p. 44–46.)For example, younger patients are more likely to be aggressive than older patients Aggression is а frequent and problematic aspect of psychiatric inpatient treatment (Infantino, 1985, p. 1312–1314) Previous research has shown that many of the same demographic characteristics associated with aggression in psychiatric inpatients are associated with aggression in the general population (McCrae, 1987, p. 81–90). For example, younger patients are more likely to be aggressive than older patients.

Forms of Aggression

        The common forms of aggression are as follows:

  • Verbal aggression
  • Threatening verbal aggression
  • Humiliations
  • Provocative aggressive behaviour
  • Passive aggression
  • Threatening physical behaviour
  • Destructive aggressive behaviour
  • Mild physical violence
  • Severe physical violence
  • Mild violence against self
  • Severe violence against self
  • Suicide attempts
  • Completed suicides
  • Sexual intimidation/harassment
  • Sexual assaults/rape

Inconsistent findings have been reported on the relationship between gender and aggression, some studies reporting no relationship (Oud, 2001) and others reporting that women are equally or more frequently aggressive than men (Kay and Nijman, 2002, p. 167–175), or that men are more aggressive than women. In forensic facilities females tend to be more aggressive than males. Those studies focusing on clinical characteristics have differentiated aggressive from non-aggressive patients on the basis of diagnosis specifically they have generally found the diagnosis of schizophrenia to be more often related to aggression than other mental disorders (Hodgins, 1994). Similarly, psychotic symptomatology, mania and the emotional concomitants of psychotic symptoms (Wistedt, 1990, p. 249–252) have differentiated aggressive and non-aggressive inpatients.

        Command auditory hallucinations (Wistedt, 1990, p. 252–260) and persecutory delusions (Wistedt, 1990, p. 262–265) may have а significant and direct influence on aggression. Likelihood of aggression is influenced by the course of the illness and the nature of its treatment. In some studies active symptomatology rather than presence of diagnosed disorder per se has been associated with aggression. (Palmstierna, 1987, p. 657-663.)

        A range of cognitive, affective, and behavioural characteristics of inpatients may also contribute to aggression. However, when compared with demographic and clinical characteristics, these have been studied infrequently, particularly among forensic psychiatric patients, despite recognition that some of these characteristics, specifically anger and impulsivity, contribute to the aggression of non-mentally disordered offenders and psychiatric patients living in the community (Silver, 1991, p. 572-580). In one of the few studies examining the role of anger in inpatient (Silver, 1991, 582–592) found anger to be the strongest predictor of physical aggression in psychiatric inpatients. Further, (Silver, 1991, p. 601-602) found that impulsiveness, when interacting with an aggressive attribution style, increased the risk of violence in mentally ill patients.

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        Although the relationship has not been studied extensively, assertion may play а significant role in the inpatient setting as aggression towards staff is frequently precipitated by conflict over demands, or after requests have been refused by staff. As part of an ongoing program of research into inpatient aggression by the Victorian Institute of Forensic Mental Health, the study described here was initiated to ascertain the extent to which various demographic, clinical, affective, and behavioural characteristics relate to aggression. (Paxton, 1997, p. 149-167)

        The identification of characteristics associated with aggression may contribute to risk assessment research and assist in the prevention ...

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