Understanding staff-level factors and patient aggression in psychiatric hospitals

Background: The cause of patient aggression is a very complex question, and it continues to be a challenging phenomenon in psychiatric inpatient services. This thesis provides a broad investigation into nursing staff attitudes towards inpatient aggression. Individual factors such as the history of violence are well studied. However, staff-level factors have received less attention. Aims and Objectives: The main purpose of this thesis was to explore and expand the knowledge base of nursing staff attitudes toward patient aggression in secure psychiatric hospitals. The four questions of this thesis were; 1. What does the literature suggest about the psychological and emotional effects of inpatient aggression on nurses working in psychiatric settings? (Chapter 2). 2. What are the factors associated with nurses’ attitudes towards patient aggression in UK secure psychiatric hospitals? (Chapter 4). 3. Is the Attitude Toward Aggression Scale (ATAS; Jansen et al., 2006a; 1997; 2005b) a suitable measure for assessing nurses’ attitudes towards patient aggression? (Chapter 3). 4. What are the benefits of using a direct staff-level intervention that utilises the positive behavioural support (PBS) philosophy when targeting attitudes towards patient aggression? (Chapter 5). Method: To answer the first research question a systematic review was completed to explore current literature focusing on the psychological and emotional effects of patient aggression (Chapter 2). A critical review was then conducted to explore the psychometric properties of the ATAS, a tool commonly used within psychiatric services to help monitor and evaluate attitudes towards patient aggression (Chapter 3). An empirical research study using quantitative measures was developed to explore nursing staff attitudes towards patient aggression in UK secure psychiatric hospitals (Chapter 4). Finally, a case study presents the effectiveness of a direct staff-level intervention on nurses’ attitudes and the management of patient aggression in a secure psychiatric hospital (Chapter 5). Overall Findings: 1. The systematic review (Chapter 2) identified several psychological and emotional effects when exposed to inpatient aggression. Psychiatric nurses were found to suffer from occupational stress, psychological strain and post-traumatic stress disorder symptoms. State anxiety was found to be the main emotional effect. 2. The psychometric review of the ATAS (Chapter 3) raised questions regarding the face validity, content validity, predictive validity, concurrent validity, and construct validity. The internal reliability was deemed satisfactory, whereas the test-retest reliability is yet to be explored. 3. The results from the primary study (Chapter 4) showed that the respondents viewed patient aggression as destructive. Verbal aggression was the most prevalent predictor for the communicative, protective, and intrusive attitude domains, whilst working with the female population was associated with having a destructive attitude. 4. This case study (Chapter 5) highlights the benefit of conducting a direct staff-level intervention when targeting attitudes towards patient aggression. There was a positive shift in how staff evaluated patient aggression following this intervention. The data also evidenced improvements in the patient’s ability to cope with anger-provoking situations, along with a reduction in the frequency and intensity of aggressive incidents. Conclusion: Nurses’ attitudes towards patient aggression have been found to influence the type of management strategies used. A better understanding of the sources of them may provide a useful guide when designing and developing cost-effective organisational interventions aimed to reduce the need for restrictive interventions in inpatient settings. This can help promote positive and proactive care and create a safer environment for both patients and staff