Aggression Management Training in Psychiatric Units

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Table of Contents

Nursing Staff
Background
Significance
Problem Statement
Literature
Purpose Statement
References
Annotated Bibliography

Nursing Staff

In healthcare settings, aggressive behavior exhibited by acutely ill clients is a pervasive problem contributing to poor outcomes for both patients and medical staff. It is widespread in inpatient mental health units, where 7.8 cases are reported per 100 medical workers yearly, with nurses being the most likely victims (United States Bureau of Labor Statistics [USBLS], 2018). The agency further links the high risk of physical and verbal aggressive behaviors to a severe psychiatric diagnosis, use of restraints, substance abuse, and anticonvulsants taken by epileptic patients. Patient aggression towards the nursing staff is recognized as a significant impediment to quality care delivery in psychiatric hospitals. Odes et al. (2020) establish that the experience of violent acts has adverse physical and psychological effects on healthcare workers. Particularly severe instances of aggression may prompt the nursing staff to require time away from work, thus causing staffing issues for the unit. In fact, the data by the USBLS (2018) suggests that 69% of nonfatal patient aggression incidents remove nurses from active duty for at least some time. Therefore, aggression management training appears to be a significant point of improvement for the field.

Background

History/evolution of the Problem

Instances of aggression exhibited by psychiatric facility patients have been observed throughout the history of this field of research. Trifu et al. (2020) state that such cases are prevalent in most psychiatric settings, as conditioned by the pathology of the patients’ brain structures. These changes affect their behavioral and decision-making patterns, prompting a more aggressive response to treatment procedures. Furthermore, many of these patients are placed in psychiatric facilities involuntarily. While the prevalence of aggression has been reduced by updating treatment conditions and methods, the inherent inclination toward violence has persisted until today.

Statistics Associated with the Problem

In most cases, the instances of aggression are caused by the very nature of psychiatric treatment. Unlike other areas of healthcare, this field sees an increased number of patients who receive services involuntarily. According to the statistics provided by Wellens et al. (2021), the share of involuntary patients across psychiatric units varies from 21.5% to 100%, the average figure being over 60%. Furthermore, this research reports an average of 43.5% of patients involved in aggression incidence during the in-patient treatment phase (Wellens et al., 2021). These figures imply that the nurses involved in psychiatric care face a 50% chance of becoming the victims of patient aggression. Therefore, the problem at hand is quite prevalent within the current healthcare system, in spite of the major improvements in treatment conditions. It is possible that there is a certain minimum level to which patient aggression can be reduced by passive means. Therefore, a more efficient, proactive intervention needs to be designed and implemented to ensure further progress.

Significance

Impact of the Problem to Healthcare Systems

The problem in question has a direct impact on the healthcare system on several levels. First of all, aggression reflects the poor mental condition of psychiatric patients. Evidently, some of their cases imply such instances by default, as they are inherently related to the brain tissue damage. Nevertheless, other instances are likely to be the direct consequence of the hardships of being in a psychiatric unit. In spite of the recent improvements, such wards are associated with difficult conditions and constraints that prompt patients to become aggressive. As a result, nurses become the target for such assaults, which damages their ability to fulfill their duties. Aggression hurts nurses on a physical level, resulting in a variety of injuries and even risks to their lives. Furthermore, such experiences inflict mental damage, forcing nurses to take some time away from work or even withdraw from the field completely. This way, the efficiency and staffing of psychiatric care is affected in a highly negative manner.

Cost of the Problem

The problem becomes a costly ordeal for all parties involved and for the system, in general. From the patient’s perspective, acts of aggression may lead to the re-evaluation of their treatment progress, thus prolonging their stay at the facility. It can also lead to more legal charges resulting from their action. Whenever nurses withdraw from duty in the fallout of patient aggression, their units also experience financial damages First of all, in the most severe cases, the victims of aggression may be eligible for compensation on behalf of their employer. Second, the absence of a nurse is likely to undermine the unit’s ability to function normally. As a result, the operations are disrupted, causing financial losses for the organization by running at low patient census.

Problem Statement

Patient-initiated aggression is a significant problem in psychiatric units since patients are not likely to accept treatment voluntarily. While traditional methods such as seclusion and restraints may be used to curb aggressive behavior, they are less effective and exacerbate frustration, anger, and aggression (Weltens et al., 2021). Registered nurses (RNs) provide continuous direct care to patients admitted to psychiatric units, and thus, are at a higher risk of aggression than other healthcare workers. Aggressive behavior by patients negatively impacts nurses’ well-being and performance. The experience of violent acts may make nurses feel unsafe to deliver quality psychiatric care needed for recovery and increase burnout, which leads to high turnover (Weltens et al., 2021). Therefore, patient-initiated violence is an occupational hazard that impacts clinical outcomes for both patients and healthcare workers.

Nursing staff provide important therapeutic care required for the recovery of patients with psychiatric conditions. However, there is a knowledge gap on effective de-escalation and defense techniques for dealing with aggression to create a safe environment for both nurses and patients (Fröhlich et al., 2018). Providing an educational intervention focusing on risk identification, de-escalation, and communication is necessary to help enhance nurses’ perceptions of safety. As a result, they will be confident and competent in curbing aggression and reducing the risk of harm to themselves and the patient.

Literature

PICOT

In nurses working with psychiatric patients with a history of violence in an inpatient psychiatric hospital, how does an hour of aggression management training and a follow-up badge buddy with reminder on de-escalation techniques compared to no training affect their perception of safety within one month post-training?

Description of Search

In order to research promising interventions that can resolve the specified issue, a rigorous examination of the contemporary body of literature has been conducted. For this purpose, data was retrieved from the leading databases of academic knowledge, including Science Direct, ProQuest, and the U.S. National Library of Medicine. In addition, statistical data was sought across different federal organizations, such as the United States Bureau of Labor Statistics. The search was completed with the use of relevant key words: patient aggression statistics, psychiatric patient aggression (effect / nursing / nurse turnover / intervention), psychiatric patient de-escalation. As per the inclusion criteria, all reviewed sources were to be published within the past five years in English and be directly related to the subject matter.

Synthesis of Literature

This analysis will carefully assess the correlation between the presence of aggression management training in nurses’ experience working with mentally ill patients and their perception of safety. In this case, nurses’ perception of safety is the dependent variable. The independent variable includes the experience of attending the training and the time that has passed since it. Given the importance of the problem described above, this synthesis can provide critical evidence for the benefits of such training at different distances. Below is a more detailed description of the variables considered in this paper.

Perception of Safety

This dependent variable needs to be measured only through specially designed interviews or questionnaires that make it possible to assess the mental condition of nurses. The sense of security in activities with people with a mental health condition who have the potential for aggression can manifest itself in different ways (Dagenhardt et al., 2022; Hylén et al., 2019; Suchting et al., 2018). The synthesis of the literature shows that safety can become the foundation for the confident work of a nurse, for the implementation of professional and operational activities, the ability to make contact and maintain it, and also opens up the possibility of using various techniques and methods that are not available in case of a sense of danger. Questionnaires should be compiled so that all possible aspects in one way or another affecting the efficiency and quality of operational activities and the internal mental state of the nurse will be taken into account (Vincent-Höper et al., 2020; Tsaras et al., 2018). Nevertheless, the question of the objectivity of assessing the safety of the situation of working with a potentially aggressive patient remains open, and more specific mechanisms may be developed in the future, that have a form different from trainings and reminders.

Buddy Badge Reminder

The presence of a badge with a reminder of the potential hazard and the main countermeasures can serve as a proactive measure in preventing irreversible negative consequences for nurses’ health. However, the badge may not bring the desired result, so its impact must be evaluated in conjunction with the training. In essence, the research question, in this case, will test the effectiveness of the badge as an element of creating a safe environment in communicating with mentally ill patients and, accordingly, the need to use it after the training.

Aggression Management Training

Training differs in its approaches and depends on many external and subjective factors dictated by a particular situation. Just as the sense of security for each nurse is also a subjective measure, the presence of a threat can be assessed by nurses’ experience, their self-confidence, the presence of elements of a safe environment, and much more. In addition, the form of training should rely on the given conditions and assumptions indicated in the studies (Jalil et al., 2020; Ye et al., 2021; Odes et al., 2020; Razzani et al., 2020). As a result, creating a unique model at the system level will be a somewhat complex multi-criteria task, and therefore, at the first stage, it is proposed to implement those training methods that have already proven themselves on the positive side in research.

Strength of the Evidence

Research on this topic was conducted locally, with small samples and a relatively significant influence of external subjective factors. Nevertheless, each work on this topic covered various psychological aspects of the problem, creating a broad base for building complex universal approaches. The research also shows that as attention to the problem increases, more and more risk management approaches are being developed that can be further presented to nurses in the form of training. Cases of constant tension and incidents in the workplace lead to burnout and mental problems for nurses. In this regard, the emphasis in research is on nurses and their condition to mitigate risks. The problem of the emergence of aggression in patients also requires additional study, but it is more complex, involving many obstacles in the study. Finding a correlation between the benefits of training and the nurses’ sense of security may be more effective in clinical practice than delving into the specifics of psychiatry.

Purpose Statement

The purpose of this project is to prove the correlation between the presence of training in working with mentally ill patients who have been subjected to a history of violence in the experience of nurses and their sense of security after a certain period after these pieces of training.

References

Dagenhardt, R. D., Heideman, A., Knoche, V., & Freiburger, T. (2022). An evaluation of a de-escalation conflict management training in a behavioral health hospital setting.International Journal of Conflict Management, 33(1), 84-110.

Drukker, M. (2021). Aggression on the psychiatric ward: Prevalence and risk factors. A systematic review of the literature.Plos One, 16(10), 1-34.

Fröhlich, D., Rabenschlag, F., Schoppmann, S., Borgwardt, S., Lang, U. E., & Huber, C. G. (2018). Positive effects of an anti-aggression and de-escalation training on ward atmosphere and subjective safety may depend on previous training experience. Frontiers in Psychiatry, 9, 134.

Hylén, U., Engström, I., Engström, K., Pelto-Piri, V., & Anderzen-Carlsson, A. (2019). Providing good care in the shadow of violence – An interview study with nursing staff and ward managers in psychiatric inpatient care in Sweden.Issues in Mental Health Nursing, 40(2), 148-157.

Jalil, R., Huber, J. W., Sixsmith, J., & Dickens, G. L. (2020). 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.International Journal of Mental Health Nursing, 29(3), 427-439.

Odes, R., Chapman, S., Harrison, R., Ackerman, S., & Hong, O. (2020). Frequency of violence towards healthcare workers in the United States’ inpatient psychiatric hospitals: A systematic review of literature. International Journal of Mental Health Nursing, 30(1), 1-20.

Razzani, B., Atashzadeh-Shoorideh, F., Jamshidi, T., Barkhordari-Sharifabad, M., Lotfi, Z., & Skerrett, V. (2020). The effect of education around ethical principles on nurses’ perception to patient safety culture in an Iranian mental health inpatient unit: A pilot study. BMC Nursing, 19(10), 1-7.

Suchting, R., Green, C. E., Glazier, S. M., & Lane, S. D. (2018). A data science approach to predicting patient aggressive events in a psychiatric hospital.Psychiatry Research, 268, 217-222.

Trifu, S. C., Tudor, A., & Radulescu, I. (2020). Aggressive behavior in psychiatric patients in relation to hormonal imbalance. Experimental and Therapeutic Medicine, 20(4), 3483-3487.

Tsaras, K., Daglas, A., Mitsi, D., Papathanasiou, I. V., Tzavella, F., Zyga, S., & Fradelos, E. C. (2018). A cross-sectional study for the impact of coping strategies on mental health disorders among psychiatric nurses.Health Psychology Research, 6(1).

Ulrich, R. S., Bogren, L., Gardiner, S. K., & Lundin, S. (2018). Psychiatric ward design can reduce aggressive behavior. Journal of Environmental Psychology, 57, 53-66.

United States Bureau of Labor Statistics. (2021). Incidence rates of nonfatal occupational injuries and illnesses by industry and case types, 2020.

Vincent-Höper, S., Stein, M., Nienhaus, A., & Schablon, A. (2020). Workplace aggression and burnout in nursing—the moderating role of follow-up counseling. International Journal of Environmental Research and Public Health, 17(9), 3152.

Weltens, I., Bak, M., Berhagen, S., Vandenberk, E., Domen, P., van Amelsvoort, T., & Drukker, M. (2021). Aggression on the psychiatric ward: Prevalence and risk factors. A systematic review of the literature. Plos One, 16(10), 1-34.

Ye, J., Xia, Z, Wang, C., Liao, Y., Xu, Y., Zhang, Y., Yu, L., Li, S., Lin, J., & Xiao, A. (2021). Effectiveness of CRSCE-based de-escalation training on reducing physical restraint in psychiatric hospitals: A cluster randomized controlled trial. Frontiers in Psychiatry, 12, 1-11.

Annotated Bibliography

Reference	Setting / Sample Size	Purpose of the study/Outcome Measures	Research Design / Level of Evidence/ Intervention / Theoretical Framework (if used)	Limitations/ Threats to validity/ Results
Al Mutairi, T. S., Salih, E., Olayres, H., Jayaraman, I., & Adam, M. A. A. (2021). Reducing physical restraint rate: A quality improvement study in an acute psychiatric unit, Prince Sultan Military Medical City (PSMMC). International Journal of Current Research, 13(5), 17566-17574. Web.	Setting: Acute psychiatric wards at Prince Sultan Military Medical City Sample: Included all inpatients in male and female wards (19-64 years). Inclusion criteria: No comorbidities and aged >19 years.	Purpose: To determine restraint use prevalence, decrease this rate, and enhance perceived staff/patient safety. Outcome measures: Restraint use data recorded in the Restraint Incident Log Book (RILB).	Design: A quality improvement project based on the FOCUS-PDCA models. Level of Evidence: V Theoretical Framework: PDCA (Plan, do, check, and act) cycle.	Limitations: Intervention plan may not work on other facilities and not all patients admitted were included in the study. Threats to validity: RILB has not been validated. Results: A significant decline in the rate of physical restraint use was obtained after two PDCA cycles by 2020 due to effective communication and risk assessment skills imparted through the intervention.
Dagenhardt, R. D., Heideman, A., Knoche, V., & Freiburger, T. (2022). An evaluation of a de-escalation conflict management training in a behavioral health hospital setting. International Journal of Conflict Management, 33(1), 84-110.	Setting: Behavioral health setting providing psychiatric crisis services to Midwestern County communities. Sample: n = 447 psychiatric staff at the facility. No inclusion criteria are specified.	Purpose: To assess the efficacy of a conflict management educational intervention in increasing RNs’ capacity to handle aggressive situations. Outcome measures: Questionnaires administered to participants. Tools included the Oldenburg Inventory for measuring burnout and scales for RN confidence and skill usage.	Design: A mixed-methods approach with pre-training and follow-up surveys. Level of Evidence: IV Intervention: 8-hour de-escalation training program focusing on redirecting, persuading, and managing conflict. Theoretical Framework: None	Limitations: Absence of control group, only one organization was examined, and inaccuracies in self-reported data. Threats to validity: Validity was established for outcomes and scales, for example, subscales for conflict resolution skills (Cronbach alpha = 0.80). Results: The training reduced role conflict and fatigue among nurses and increased perceived ability to protect oneself against aggression.
Fröhlich, D., Rabenschlag, F., Schoppmann, S., Borgwardt, S., Lang, U. E., & Huber, C. G. (2018). Positive effects of an anti- aggression and de-escalation training on ward atmosphere and subjective safety may depend on previous training experience. Frontiers in Psychiatry, 9(134), 1-4.	Setting: Psychiatric University Clinics, Basel, Switzerland. Sample: n = 91 nurses (42 female; 49 male) from 22 psychiatric wards participated in a 5-day anti-aggression and de-escalation (ADE) training. Inclusion criteria: nurses working at the Psychiatric University Clinics	Purpose: Evaluate the effects of ADE training on nurses’ perception of “patient coherence, ward atmosphere, subjective safety, and therapeutic hold” (Fröhlich et al., 2018, p. 3). Outcome measures: Essen Climate Evaluation Schema (EssenCES)	Design: A cross-sectional study conducted at two time intervals: 2012 and 2016. Level of Evidence: IV Intervention: Nurses received ADE training in groups 12-15 participants for five days. Theoretical Framework: None	Limitations: Small sample size and longer intervals between assessments. The cross-sectional design was also a limitation. Only data on gender was obtained; thus, other confounds may affect the findings. Threats to validity: None. EssenCES has been validated empirically (Cronbach α = 0.79). Results: The ranking of patient coherence, safety, and inpatient environment by first-time ADE trainees was significantly higher than that by previously trained nurses (p = 0.001).
Hylén, U., Engström, I., Engström, K., Pelto-Piri, V., & Anderzen-Carlsson, A. (2019). Providing good care in the shadow of violence – An interview study with nursing staff and ward managers in psychiatric inpatient care in Sweden. Issues in Mental Health Nursing, 40(2), 148-157.	Setting: Swedish psychiatric wards. These units provided general, forensic, and addictive services Sample: Nurses (n = 17) and ward managers (n = 3); no inclusion criteria, as purposeful sampling was used.	Purpose: To describe the nurses’ and unit managers’ experiences of aggression when interacting with patients. Outcome measures: None	Design: A qualitative inductive design was used. Data collection involved focus group interviews. Level of Evidence: VI Intervention: None Theoretical Framework: None	Limitations: Only a single ward from each specialty was sampled – the sample may not be representative. – A small sample size Threats to validity: No measurement tool was utilized; The validity of interview guide cannot be determined. Results: Nurse-patient relationship supports safety, hospital culture impacts care delivered, and self-management requires education to build patient self-care competence.
Jalil, R., Huber, J. W., Sixsmith, J., & Dickens, G. L. (2020). 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. International Journal of Mental Health Nursing, 29(3), 427-439.	Setting: Adult psychiatric wards, St. Andrew’s hospital, UK. Sample: 85 inpatients (>18 years) and 65 RNs. Inclusion criteria: capacity to consent and English speakers.	Purpose: To evaluate self-reported aggression and interpersonal styles that mediate nurse-patient relationships in psychiatric settings. Outcome measures: Outcomes included anger, interpersonal styles, and PR use. Tools used were Novaco anger scale (NAS), Impact Message Inventory (IMI), Overt Aggression Scale (OAS), etc.	Design: A correlational, pseudoprospective cohort study was conducted over three months. Level of Evidence: IV Intervention: None Theoretical Framework: Interpersonal Theory	Limitations: Only one nurse per patient was included – caregiving involves many RNs; antecedents of aggression were not studied. Threats to validity: Instruments were reliable: NAS (Cronbach’s alpha 0.94), IMI (Internal consistency = 0.69-0.85), and OAS (inter-rater reliability = 0.74) Results: Nurse-patient relationships were not complementary. A positive correlation was found between self-reported rage and interpersonal style for RNs and patients.
Kabangu, P. (2021). The impact of hand-on training in the implementation of verbal de-escalation techniques to manage trauma related aggressive behaviors in a forensic psychiatric facility. International Journal of Mental Health and Psychiatry, 7(3), 1-6.	Setting: The admission unit of a 33-bed forensic psychiatric hospital in California Sample: n= 9 nurses, including RNs and psychiatric technicians and their assistants. No inclusion criteria given.	Purpose: To examine strategies nurses use to resolve aggression displayed by psychiatric patients and improve their self-efficacy. Outcome measures: Pre- and post-training confidence; the measurement tool was Confidence in Coping with Patient Aggression (CCWPA).	Design: A mixed-methods study using in-depth interviews. Level of Evidence: VI Intervention: De-escalation training delivered one-on-one with participants. It contained theoretical and hands-on aspects. Theoretical Framework: None	Limitations: A small number of participants and verbal de-escalation implementation delays. Threats to validity: The validity and reliability of CCWPA has been established (Cronbach alpha = 0.96) Results: De-escalation training that incorporates theoretical and practical aspects enhanced nurses’ self-efficacy in dealing with aggression, resulting in lower violence-related injuries.
Nyman, M., Hofvander, B., Nilsson, T., & Wijk, H. (2020) Mental health nurses’ experiences of risk assessments for care planning in forensic psychiatry. International Journal of Forensic Mental Health, 19(2), 103-113.	Setting: Swedish forensic psychiatric facilities in two sites. Sample: n = 15 nurses purposively sampled. No inclusion criteria used.	Purpose: To investigate nurses’ use of risk evaluation and management in care planning in mental health settings. Outcome measures: None	Design: A qualitative study using focus group interviews. Level of Evidence: VI Intervention: None Theoretical Framework: Peplaus’ theory of interpersonal relations and person-centered philosophy.	Limitations: The deductive approach forced data into themes and researcher preconceptions about the study. Threats to validity: Qualitative content analysis was done by two researchers. Results: RNs consider the unique needs of the patient, regardless of his or her violent history. They also saw a therapeutic alliance as a protective factor.
Odes, R., Chapman, S., Harrison, R., Ackerman, S., & Hong, O. (2020). Frequency of violence towards healthcare workers in the United States’ inpatient psychiatric hospitals: A systematic review of literature. International Journal of Mental Health Nursing, 30(1), 1-20.	Setting: The settings for the articles included in this systematic review ranged from small mental health hospitals in New Jersey and California to larger federal forensic facilities in Washington and VA facilities spread across the US. Sample: 14 articles mainly comprising retrospective cohort and cross-sectional studies were included in the final evaluation.	Purpose: To evaluate the degree or prevalence of patients’ violence or aggression towards caregivers in inpatient health settings across the US. Outcome measures: Rates of workplace violence. Outcome measurement tools included “the Modified Overt Aggression Scale, the Staff Observation Aggression Scale, the Psychiatric Nurse Stress Inventory, and other Likert-type scales” (Odes et al., 2020, p. 15).	Design: A systematic review was conducted Level of Evidence: 5 Intervention: A nurse-driven intervention called Violence Prevention Community Meeting. Only one intervention study was included. Theoretical Framework: One study used the Person-Environment Fit theory. Another one reported “Conservation of Resources Theory and Social Exchange Theory” as useful models for understanding workplace violence (Odes et al., 2020, p. 8).	Limitations: None Threats to validity: None Results: Workplace violence in America’s inpatient mental health setting is a prevalent issue. Overall, 25-85% of respondents experienced physical violence (Odes et al., 2020).
Razzani, B., Atashzadeh-Shoorideh, F., Jamshidi, T., Barkhordari-Sharifabad, M., Lotfi, Z., & Skerrett, V. (2020). The effect of education around ethical principles on nurses’ perception to patient safety culture in an Iranian mental health inpatient unit: A pilot study. BMC Nursing,19(10), 1-7.	Setting: Four psychiatric inpatient units in an academic hospital, Tehran, Iran. Sample: n = 33 nurses (mean age = 35.6 years; 27 female, 6 male) Inclusion criteria: > bachelor’s degree, >1 year experience, and no previous ethical training.	Purpose: To evaluate the effect of training on ethical principles of nurses’ perception of safety in mental health wards. Outcome measures: Perception of patient safety; the measurement tool was an adapted Hospital Survey on Patient Safety Culture (HSOPSC)	Design: Pre- and post-intervention descriptive study Level of Evidence: VI Intervention: Educational intervention on ethical principles offered in four weekly face-to-face sessions lasting one hour. Theoretical Framework: None	Limitations: Small sample size; one educational hospital was examined, which reduces generalizability of the results. Threats to validity: HSOPSC has high internal consistency (correlation coefficient = 0.85). Results: Post-intervention patient safety perception score increased to 143.6 from a baseline level of 116.9. Further, 42.4% of nurses reported that patient safety was excellent after the training compared to 45.5% at baseline.
Spencer, S., Johnson, P., & Smith, I. (2018). De‐escalation techniques for managing non‐psychosis induced aggression in adults. Cochrane Database of Systematic Reviews Issue, 7, 1-42.	Setting: Diverse care settings, including social care environments, in France. Sample: 2 RCTs met the inclusion criteria out of 7,484 studies and were included in the systematic review. Inclusion criteria: Full-text reports and RCTs.	Purpose: To evaluate de-escalation methods for handling non-psychotic aggression in psychiatric patients. Outcome measures: Primary outcomes: Frequency of aggressive incidents and injuries Secondary outcomes: length of stay and staff absenteeism Tools: De-escalating Aggressive Behavior Scale.	Design: A systematic review of RCTs Level of Evidence: I Theoretical Framework: None	Limitations: Small number of studies included Threats to validity: None Results: Staff training reduced physical and verbal aggression; however, the prevalence of injuries sustained by nurses could not be ascertained.
Weltens, I., Bak, M., Berhagen, S., Vandenberk, E., Domen, P., van Amelsvoort, T., & Drukker, M. (2021). Aggression on the psychiatric ward: Prevalence and risk factors. A systematic review of the literature. Plos One, 16(10), 1-34.	Setting: The settings for studies reviewed included acute medical units and rehabilitation wards that were either open or closed Sample: 146 studies, including case-control and RCTs	Purpose: To identify patient, healthcare worker, and ward factors that cause aggressive behavior in mental health wards. Outcome measures: Aggression, violence, distress, and physical attacks. Several measurement tools included “Staff Observation Aggression Scale (SOAS), Overt Aggression Scale, Positive and Negative Symptom Scale-Excited Component (PANSS-EC), and the Social Dysfunction and Aggression Scale (SDAS)” (Weltens et al., 2021, p. 27).	Design: A systematic review was conducted Level of Evidence: I Intervention: The studies reviewed reported interventions, such as denial of cigarettes and reprimands, to control aggressive behavior Theoretical Framework: None	Limitations: Poorly described definitions of violence or aggression in literature, only papers in English were considered, and studies used a variety of measurement tools with no proven validity and reliability. Threats to validity: None Results: The prevalence of aggression in psychiatric wards was 8-76%. Patient risk factors included presence of psychological disorders and being young. Staff factors included job dissatisfaction and fatigue, while ward-related causes were high bed occupancy and limited safety.
Ye, J., Xia, Z, Wang, C., Liao, Y., Xu, Y., Zhang, Y., Yu, L., Li, S., Lin, J., & Xiao, A. (2021). Effectiveness of CRSCE-based de-escalation training on reducing physical restraint in psychiatric hospitals: A cluster randomized controlled trial. Frontiers in Psychiatry, 12, 1-11.	Setting: A provincial 1,920-bed public psychiatric facility in Guangdong, China. Sample: 12 wards were randomized into experimental group (n = 6) and control arm (n = 6); 22.33 vs. 23.50 RNs. Inclusion criteria: nursing staff in the psychiatric ward	Purpose: To examine the efficacy of CRSCE (Communication, Response, Solution-Focused Technique, Care, and Environment)) –based de-escalation education on decreasing physical restraint (PR) use. Outcome measures: Frequency and duration of PR; no measurement tool used	Design: Cluster randomized controlled trial Level of Evidence: II Intervention: Experimental group (wards) received a 1-month CRSCE-based education comprising lectures and practical experiences. Theoretical Framework: None	Limitations: Only one psychiatric facility was examined – limited generalizability of findings. – No pre- and post-intervention outcomes were measured for nurses. Threats to validity: None; objective outcome indicators for frequency and duration of PR were used. Single blinding also removed bias. Results: Post-training PR frequency and duration was significantly lower in trained wards than in the controls (p < 0.01).

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