Saraswathy Subramaniam 0809 BSc Mental Health

Introduction

Justify the management of aggression and violence behaviour in mental

health setting.

Chapter 2

Methodology

This chapter’s aim is to describe the detailed process of literature review and
the research based articles and journals which will be used in this study along
with various critiquing tools. According to Cooper, H. M. (1988) "a literature
review uses as its database reports of primary or original scholarship, and
does not report new primary scholarship itself. The primary reports used in the
literature may be verbal, but in the vast majority of cases reports are written
documents. The types of scholarship may be empirical, theoretical,
critical/analytic, or methodological in nature. Second a literature review seeks
to describe, summarise, evaluate, clarify and/or integrate the content of
primary reports."

In the various chapter of the methodology, will critically discuss all the
methods used to complete the systematic literature review and to provide the
reader with a sound rationale for the decisions made. It will comment on the
literature review strategy carry out in order to find the appropriate papers; the
types of evidence considered for the literature review, and data extraction
which is the inclusion and exclusion criteria; Critical framework used, where
the acquired literature was assessed through a chosen critique model and this
has been applied all the way through the literature review; and the key themes
and chapters within the research question.

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Literature review strategy

To ensure that there were enough evidence existed in order to reply the
research questions, the questions were designed by following the literature
search. Though the topic area was broad, the research questions stayed
unchanged. Even though the purpose of the literature review is to identify the
management of aggression and violence behaviour in mental health setting
and highlight on the available methods that could be adopted by the mental
health nurses or/and health professionals, it provides important information
and guidance for the development of the health professional who works in
mental health setting. The literature review was limited to the more recent and
optimistically more precise research only.

Most of the literature materials were collected from electronic database for
this literature review research. As stated by Younger (2004), electronic
database provides a vast quantity of information and gives the option to limit
the scope of search, easily saved and used and also this is important
especially when managing a large literature search. The electronic databases
used to collect the extensive relevant literature review are mainly from:
BRITISH NURSING INDEX, CINAHL, COCRAINE, PSYCINFO, ERIC,
HEALTH SOURCE, E-JOURNALS, GOOGLE, PUBMED, etc. Other websites
such as Nursing and Midwifery Council (NMC), Department of Health (DH),
and National Institute for Clinical Excellence (NICE) also been used to
conduct the search. Books from the university library and hand search
journals were used as there is a possibility in articles missed by the
computerised search.

In order to search for the appropriate literature materials, keywords will be the
main source. The keywords used to find the relevant literature, for this review
were aggression, management, violence, behaviour, mental health, causes,
patients, service user, de-escalation, breakaway, techniques, seclusion,
restraint, psychological, physical, pharmacological, intervention, literature
review, qualitative research, quantitative research, systematic review, critique,
internal factor, external factor, environmental factor and framework.
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Denzin and Lincoln (1994) has defined qualitative research as “multi-method

in focus, involving and interpretive, naturalistic approach to its subject matter.
This means that qualitative researchers study things in their natural settings,
attempting to make sense of or interpret phenomena in terms of the meanings
people bring to them” (cited in Klenke, K. 2008). According to Creswell, (2003)
"A quantitative approach is one in which the investigator primarily uses post-
positivist claims for developing knowledge (i.e. cause and effect thinking,
reduction to specific variables and hypotheses and questions, use of
measurement and observation, and the test of theories)", (cited in Einstein
2001). Both of these research methods have been used throughout the
literature review.

Inclusion and Exclusion Criteria

While doing literature review for a research, there will be some inclusion and
exclusion of research materials. The literature reviewed was related to causes
of aggression and violence behaviour in mental health setting, which
connected to internal, external and environmental factors, and techniques
used to manage the aggression and violent behaviour in mental health
setting, which connected to psychological, physical and pharmacological
intervention.

For inclusion, all the literature review materials used was in English language
and most primary literature materials used for this research were based from
United Kingdom (U.K). This will facilitate the review of the literature to be
appropriate to practice within the U.K, and in addition it allows easier
comparison among the studies which has been taken place in similar
surroundings and also ruled by the same guidelines which only applies to U.K.
Research materials from other countries such as from Australia, Netherlands,
America etc in English language has been included to support a particular
point or view. Most of the research based articles; journals and non research
based articles used were restricted to a period of up to ten years. Some
appropriates literatures which is older than ten years period were considered
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in the review as long as it provides huge information, knowledge and in fact

applicable to causes of aggression and violence behaviour and techniques
used to manage aggression and violence behaviour in mental health setting.

In order to select the appropriate articles, the author reads the title and
abstract of an article which provides the knowledge about the content of the
article and stores them rather than reading full article to save the time. To
support the research, books and other guidance document from National
Institute for Mental Health in England (NIMHE), Nursing and Midwifery
Council (NMC), National Institute for Clinical Excellence (NICE) and
Department of Health (DH) were reviewed.

Fink, A. (2009) stated that “research literature reviews can be contrasted with
more subjective examinations of recorded information. When doing a
research review, you systematically examine all sources and describe and
justify what you have done. This enables someone else to reproduce your
methods and to determine objectively whether to accept the results of the
review”. The aim of this literature review is to explore the causes of
aggression and violence behaviour and techniques used to manage
aggression and violence behaviour in mental health setting.

However for exclusion, some of the collected literature will not be included in
the review, such as from unrecognised websites and articles, some research
materials more than ten years and also from some countries due to its validity
and trustworthiness of the authors and writers. The literature connected to
violence in learning disability, sexual violence, violence in school and violence
against children will also be excluded from this study.

Critiquing Strategies

The skill to critique and evaluate research is crucial to writing a literature

review and requires an acknowledged tool to ensure a systematic process is
applied (Cormack 2000). According to Polit and Beck (2008) a research
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critique is a mechanism to provide feedback for improvement. They also

recommended that nurses who can critically review a study contribute to the
body of nursing knowledge. Within the literature review, Polit and Beck’s
qualitative and quantitative critique tool was used, making possible a
systematic approach to critiquing articles.

The technique used by Polit and Beck (2008) critiquing tool has a clear
subheading, which has absorbed easily at the same time as reviewing the
research. This provides a simple guidance and a good quality framework to
begin research based literature critique. They are appropriate in discovering
of both strengths and weaknesses for this literature review study. Polit and
Beck (2008) critiquing tool was used all the way through all papers to
establish stability and trustworthiness of the evaluation. Some of the guidance
to an overall critique of a quantitative and qualitative research report is
mentioned in Appendix I.

Key Theme and Chapter Titles within research question

While undertaking critical analysis of the research based studies, two key
themes and sub themes originated.

The themes that will form the main body of the review will be:
• Causes of aggression and violence behaviour in mental health setting.
• Techniques used to manage the aggression and violent behaviour in
mental health setting.

Themes

Causes of aggression and violence behaviour in mental health setting:

 The internal factors
 The external factors
 The environmental factors.

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Intervention used to manage the aggression and violent behaviour in mental

health setting.
 Psychological intervention
 Physical intervention
 Pharmacological intervention

Chapter 3

Causes of aggression and violence behaviour in mental health setting.

This chapter will highlight the causes of aggression and violence behaviour in
mental health setting. This theme’s main purpose is to allow the readers to be
aware of the causes of aggression and violence behaviour that takes place in
mental health setting. This theme also enables the readers to have more in
detail understanding of the term aggression and violence behaviour.

Aggression will be use to describe all verbal and physical assaults, and has
been defined as any form of behaviour that is intended to affect, and can
actually cause, physical or psychological injury, and ‘management’ is used to
encompass any response to the direct or indirect risk of aggression
behaviour, Irwin A. (2006).

Violence and aggression is referred to acts of physical violence against

others. According to Healthcare Commission and Royal College of
Psychiatrists in (2005) audit, they found that one in three inpatient service
users has faced violence or threatening behaviour and 80 per cent of nursing
staff had experience violence behaviour, Allen D. (2006). Commission,
(2007a; 2007b) cited in Stubbs B. and Dickens G. (2008) have stated that
violent and aggressive behaviour towards health professional is common in
mental health services and such behaviour pressurize the safety and well-
being of everyone and lead to physical, psychological, social and financial

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consequences for all concerned. The ‘front line’ staffs, who are the nursing
staff are at high risk of aggression and violence behaviour and these is why
the nursing students and nursing staff need to attend training in
understanding, prevention and management of violence and aggression to
face this risk, according to Healthcare Commission, (2007a; 2007b) cited in
Stubbs B. and Dickens G. (2008).

According to studies done by Katz P. and Kirkland FR. (1990) and Powell G.,
Caan W, and Crowe M. (1994) cited in Stuart H. (2003) has shown that, the
past history of aggressive incidents in inpatient setting disclose the majority of
incidents have direct link with social/structural background such as ward
atmosphere, lack of clinical leadership, overcrowding, ward restrictions, lack
of activities, or/and poor structured activity transitions.

A research study conducted by Jansen et al. (2005) using a sample size

range from 29-209 nursing staff in general hospital and 24-999 nursing staff in
psychiatric hospital to explore the staff attitudes towards aggression in mental
health setting. A quantitative approach methods and questionnaires were
used for data collection from the nursing staff. Jansen et al. (2005) aim for this
research study was to investigate the approach of health care workers
towards inpatient aggression. Research was mostly concerned with the
cognitions that nurses had regarding aggression, and attitudes were studied
only to a limited degree. The self-report questionnaire was the most common
tool used and three other instruments, was designed in particular to measure
attitudes were established. The data was analysed using tools such as The
Attitudes Towards Aggressive Behaviour Questionnaire, Attitudes Towards
Physical Assault Questionnaire, and Management of Aggression and Violence
Attitude Scale (MAVAS), and this has made it difficult to compare results
across setting in general and psychiatry hospitals. Limitation of the tools used
by author lacked profound validity testing. From a total of 74 items, two thirds
concentrating on cognitions and only a quarter actually tackled attitudes
towards aggression. Saying so, Jansen et al. (2005) found that, the cause of
violent behaviour is due to patient themselves, environmental factors,
treatment factors, and interactional factors.
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A research study conducted by Oostrom and Mierlo (2008) to identify a

systematic evaluation of the effectiveness of an aggression management
training program to help staff in mental health setting in Netherland. The
author used a convenience size of 42 participants from a mixed group such as
domestic aids, home care workers, registered nurses, and newborn and infant
care workers. This was a quantitative approach in nature and the data was
collected using three types of questionnaire, one before training (T1), one
immediately after training (T2) and one five weeks after training (T3). The
study has shown a significant increase in participants understanding of insight
into assertiveness and aggression and ability to cope with adverse working
situations. This clearly shows the support of the aggression management
training may be an effective tool to use in mental health setting. However, the
limitation of this research study was the sample size used rather small to
achieve a solid result, and also there were a loss of 36% respondents
between T2 and T3 which could have an impact on achieving the result.

Irwin A. (2006) conducted a research study using a text analysis and an

exploration of research relevant to past history of aggression and provides a
base for exploring the relationship between nursing behaviour and
development of aggression within the environment. In this research he
explained that, there is a direct relationship between aggression and
psychosis. He also found that individual with severe mental illness who have
misuse drugs and/or alcohols are more likely perpetrate aggressive acts
compare to general population. In this research, Alberg et al. (1996) and
Kumar et al. (2001) (cited in Irwin A. 2006) suggested that unfavourable staff
attitudes, stigmatic labelling, aggressive treatment, and risk of prosecution are
the possible consequences for aggressive incidents. The outcome of study on
causes of aggression was uncertain but aggression has been explained as an
individual’s response to unacceptable circumstances, environment or
situation.

A quantitative research study was conducted by Duxbury J. (2002) to identify

and assess the approaches used to manage patient aggression and violence
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on three acute mental health wards in United Kingdom. A convenience

sample size of 162 participants which includes of patient (n=80), nurses
(n=72), and medical staff (n=10) were explored. The data was collected using
a triangulation research approach such as an incident form, a questionnaire
and interviews in order to enhance confidence in the ensuing findings.
Statistical analyses were reported in the Modified Staff Observation
Aggression Scale (MSOAS) and Management of Aggression and Violence
Attitude Scale (MAVAS) correspondingly; using both descriptive and
inferential statistic. The results revealed a clear difference between the way
staff and patients view both the problem and the response. Patients’ view
current staff approaches as ‘controlling style’ and think that environmental and
poor communication reasons underpin aggressive behaviour. Staff, on the
hand, attributes violent behaviour to internal and external factors.

Duxbury and Whittington (2005) conducted a qualitative research study by

using a convenience sample size of 162 participants from a psychiatric
intensive care unit, a high dependency ward, and an acute ward, using the
Management of Aggression and Violence Attitude Scale tool (MAVAS). The
aim of this study was to identify the causes of patient aggression and the way
it is managed from the staff and patient perspectives. The data was collected
using questionnaire and semi-structured interviews by the author. According
to Rippon (2000), there are a number of theories has been developed that
attempt to explain the causes of patient aggression in mental health setting.
These can be narrowed down to three conceptual models, which is the
internal, external and situational/interactional models.

The key findings and outcomes of the internal point of view was that the
nurses viewed the patients’ mental illness as a strong antecedent to
aggression behaviour. This statement has been supported by Steinert et al.
(2000) and Nijman (2002) found a strong relationship between thought
disorders and aggression behaviour in inpatient setting. However, the patients
strongly disagree to this statement. The key findings and outcomes of the
external factors were both the patients and staff believed that environmental
conditions could trigger aggressive behaviour in mental health setting.
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Though, environment is perceives by patients as prison, locked-up, regimes

and atmosphere and by staff as ward design and structural environment. The
findings and outcomes of situational/interactional factors were identified by
patients as staffs poor communication and ineffective listening skills as
precursors to aggression. Although staff did not see their interaction as
precursors to aggression but they acknowledge that there is room for
improvement. In Nijman (2002), Gudjonsson et al. (2004) and Duxbury (2002)
they supported Duxbury and Whittington (2005) in the claim that, staffs poor
communication skills and negative staff patient relationship lead to patient
aggression and a therapeutic communication should be encouraged.
However, the limitation of this research study was the sample size involved
only three acute inpatient mental health wards. Generalizations to specialist
and non inpatient areas may not be possible even though there may be
similarities in other settings of this nature.

Bowers et al. (2006) conducted a research study using quantitative approach

through retrospective analysis of the official records with a large sample size.
The data was collected over two and a half years on 14 acute admission
psychiatric wards at three inner-city hospitals in United Kingdom. The data
was based on training records (312 course attendances), violent incident
rates (684 incidents), and (5,384) admissions. The main aim of this research
study was to explore the relationship between Prevention and Management of
Violence and Aggression (PMVA) training for nursing staff in acute psychiatric
ward and violent incident rates which been officially reported. The analysis of
this data was rather difficult for the readers to understand and less attractive.
There was a positive relationship was found between training and rates of
violent incidents in this research. A small evidence to show the increased rate
of aggressive incidents promote course attendance, no evidence to show that
course attendance have reduced the violence and some evidence to show
course update triggers short-term rise in physical aggression. The limitation of
this study was, not all 14 psychiatric wards took part throughout the two and a
half years period which will enable the researcher to find the relationship
between PMVA training for nursing staff in acute psychiatric ward and violent

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incident rates which been officially reported have an effect on the data
collection to provide solid results.
In the article, Rew, M. and Ferns, T. (2005) has highlighted the responsibilities
of employers and the strain in both hospital and community settings on staff at
danger from violent or abusive incidents. The patient's viewpoint is discussed,
suggesting that more understanding between patients and staff is needed.
The article looks at the 'NHS Zero Tolerance Zone Campaign' and whether
this can be improved by bring in training of a concerned nature along with
other useful environmental issues. It proposed that there are option, and more
efficient, techniques in dealing with violence and aggression which can be
used to calm a situation before it ever turn into a physical altercation.

Duxbury et al. (2008)

Chapman et al. (2009)

Chapter 4

Intervention used to manage the aggression and violent behaviour in

mental health setting.

The Nursing and Midwifery Council (NMC) (2002) has stated that actions
should be taken to make sure that ‘pre-registration nursing students receive
training and have achieved competence in the recognition of possibly violent
situations, de-escalation techniques, and breakaway techniques and possibly
physical restraint techniques’ as there is a strong need for the training
especially for those who works in acute mental health setting. Furthermore,
Stubbs B. and Dickens G. (2008) mentioned that there is three types of
interventions used in managing aggression and violent behaviour, which are
psychological, physical and pharmacological interventions. The most
commonly used intervention is psychological intervention, in particularly de-
escalation and physical interventions.

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Stubbs B. and Dickens G. (2008) stated that, by providing regular training to

healthcare professionals in their pre-registration programmes, particularly in
psychological interventions to de-escalate potentially violent situations could
benefit the staff that go to work in mental health setting.

Psychological Intervention.

De-escalation should be used as the first intervention in managing aggression

and violence behaviour and if the situation escalates and becomes dangerous
than staff may need to apply physical interventions according to the guidelines
given by, National Institute of Clinical Excellence (NICE), (2005). Although
there is very little evidence on the effectiveness of de-escalation but there is
less negative consequences related with its use compare to physical and
pharmacological interventions.

De-escalation is an art of bringing a situation to a possible resolution through

communicating and not force, and this art benefits from a quicker resolution
and lesser harm to the client and others. In a situation where somebody is
being aggressive towards us, we chose to fight which lead to high aggression
or flight which leads to low aggression. To de-escalate a situation, the staff
should not deny what’s happening; challenge, argue or insult the client,
instead of that staff should stay calm, with open posture, listen and negotiate
with the client. When comes to de-escalate a situation, staff should appear
confident, calm, create some space for client, speak slowly, gently and
clearly, lower their voice, avoid staring, arguing and confrontation,
demonstrate that you are actively listening and calm the situation before
solving the problem. The timing is also important in using de-escalation,
knowing when to de-escalate and when not to de-escalate a client. It is
important for staff to recognise when a client is becoming aroused, so they
could intervene earlier and de-escalate the situation.

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Even though de-escalation is not a new tool but not all the nurses have the
knowledge, confidence and skills in using de-escalation technique, according
to Cowin, L. et al. (2003). Cowin et al. (2003) also stated that the deficiency in
using de-escalation techniques are due to an increase in workloads, shortage
of staff expands and the use of casual and agency nurses who are not
specialised in mental health. There are some important elements in managing
the possible aggression and violent actions, which involves maintaining
independence and dignity for the patient, using self-knowledge to accomplish
goals, being self-aware, intervening early, providing alternative and choice,
and avoiding physical confrontations, as stated by Distasio (1994) cited in
Cowin, L. et al. (2003).

Cowin, L. et al. (2003) has defined de-escalation in his project as “a gradual

resolution of a potentially violent and/or aggressive situation through the use
of verbal and physical expressions of empathy, alliance and non-
confrontational limit setting that is based on respect”. De-escalation is
important in the acute mental health and emergency departments. By using
de-escalation, it allows the staffs to develop a therapeutic relationship with the
patients and also increase their confidence, sense of worth and gives job
satisfaction, according to Cowin, L. S. (2001) cited in Cowin, L. et al. (2003).
This study was based on a quantitative survey over 3 months period using
very small amount of nurses and only two units/departments was involved.
Although there were no significant changes found in the survey but there was
an increase in de-escalation knowledge and awareness for the nursing staff.

Kahn H and Schelling T (2010) has defined de-escalation as ‘being able to

achieve an acceptable status quo post at one’s unilateral choice, so that de-
escalation can be undertaken without sacrificing one’s wartime objectives’.
Stevenson (1991) has defined de-escalation as a ‘complex, interactive
process in which a patient is redirected towards a calmer personal space’.

According to Stokowski (2007), de-escalation is used in order to reduce the

use of seclusion and restraint. The Four S Model developed by (Delaney,
Pitula and Perraud (2000) cited in Stokowski (2007)) is to reduce seclusion
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and restrain, which is safety, support, structure and symptom management. In

this model the support is where the staff using the de-escalation technique by
listening and talking in a supportive way to the client and offering comfort
measures to calm the client.

The National Institute for Mental Health in England (NIMHE) (2004) has
published the Mental Health Policy Implementation Guide and also works
closely with the Counter Fraud and Security Management Service (CFSMS) in
relation of developing positive practice to support the safe and therapeutic
management of aggression and violence in Mental Health In-patient setting.
NIMHE (2004) has identified that bigger importance has been placed on
developing skills on physical management of aggression and violent rather
than developing skills in recognition, prevention and de-escalation, seeing that
aggression and violence often could be predicted and is often preventable.
Recognition, prevention and de-escalation should be the main centre of
attention when dealing with aggressive and violent behaviour. This will
develop a therapeutic relationship between clients and staff and encourage
mutual respect, recognise the need for privacy, dignity, racial and cultural
diversity.

The CFSMS has been developing a standard national syllabus at present for
recognition, prevention and de-escalation training and this training will be
made as a compulsory in future for selected groups of staff. In the Mental
Health Policy Implementation Guide, it is clearly stated that all the Mental
Health service providers must include the recognition, prevention and de-
escalation skills awareness training in their policies, procedures, education
and training programmes as the first line approach when responding to
aggressive behaviour, and provide the training as a part of the induction
programme. These training should be given within three months of starting
employment, to the staff who can be exposed or who may require to be
involved in managing aggression and violent behaviour. Mental Health service
provider also should provide and encourage staff to attend regular updates or
refresher education and training programmes on managing aggression and
violence behaviour.
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Allen D (2006) stated that an audit has been carried out on violence in Mental
Health by Healthcare Commission and Royal College of Psychiatrists in 2005.
In this audit they found that, by using de-escalation technique it supports a
positive change and reduced the use of restraint and seclusion, furthermore
the patients felt they were better able to negotiate, and staff felt their role was
more meaningful.

However, in a study done by Laker, C et al (2010) to investigate whether de-

escalation and physical intervention training is successful in reducing
incidents and incident severity on a Psychiatric Intensive Care Unit (PICU)
and found there were no differences in the number or severity in incidents
before or after the training in de-escalation and physical intervention. They
also stated that the data were recorded inconsistently or inaccurately which
made it difficult to evaluate the intervention to improve the safety of the
inpatient services.

Although in this study, Laker, C. (2010) have looked into incidents which
occurred in 12 months time-frame and include all the incidents where de-
escalation and restraint techniques was needed to resolve the situation but
this was divided into two groups, where the comparison was done 6 months
before the training and 6 months after the training. This was very short time-
frame to compare as some staff may take longer time to develop their
confidence level in order apply the training into practice. In this study it has
been stated that more agency staff were used and when incidents occurred,
the incidents were mainly dealt by the agency staff who has not received
training on de-escalation or restraint. Furthermore this case study was limited
to one PICU specialist ward and not generalisable to other areas. The
research might consider other clinical areas and more than one Trust.

Physical Intervention

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Physical intervention is physical restraint, which is a skilled and manual

method and should be used by three trained staff with the purpose of
controlling the aggressive patient and restoring safety in the clinical
environment, as per NICE (2005) guidelines. The Royal College Psychiatrists,
(1998) cited in Stubbs B. and Dickens G. (2008), stated that some research
have found training and experience in physical intervention has minimise staff
injuries, although there is no clear evidence on overall reduction of violence.
Breakaway is another skills used under the physical intervention and this
could be used by one person or more. This is a technique used by staff to
successfully remove themselves from patient who holds to the body such as
hair-pulling, strangleholds, wrist-grabs, bear hugs, full nelsons and close
proximity holds, Rogers et al (2007).

Seclusion is also part of physical intervention, and only used as a last resort if
the patient continues to be aggressive after the use of physical restraint. That
means the patient need to be removed from that environment for the safety of
the patient and others, Stubbs B. and Dickens G. (2008). The Department of
Health (DH), (1999) cited in Stubbs B. and Dickens G. (2008) has defined
seclusion as “the supervised confinement of a patient in a room which may be
locked to protect others from significant harm. Its sole aim is to contain
severely disturbed behaviour which is likely to cause harm to others”.

Pharmacological Intervention

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