Perception of aggression among psychiatric nurses in Switzerland

OBJECTIVE: To identify principal components and patterns in the perception of aggression by psychiatric nurses and to explore relationships between the perception of aggression and personal and workplace characteristics. METHOD: Seven hundred and twenty-nine nurses working in psychiatric inpatient departments of German-speaking Switzerland completed the perception of aggression scale (POAS). Data analysis included factor analysis, group comparisons and multivariate analysis of covariance. RESULTS: Two plausible factors were identified, representing different dimensions in the perception of aggression and accounting for 35% of the variance. Firstly, aggression is perceived as dysfunctional/ undesirable and, secondly, aggression is perceived as a functional/ comprehensible phenomenon. Only minor differences were found in the perception of aggression with regard to personal characteristics or work environment of the nurses. CONCLUSION: Nurses perceive aggression not just as a negative phenomenon. The perception of aggression as measured by POAS is independent of many characteristics expected to be related to the perception of violence, such as grade of education, work experience, etc.     

Predicting adolescent violence: impact of family history,substance use,psychiatric history,and social adjustment

OBJECTIVE: The aim of this study was to provisionally develop an efficient screening method to detect adolescents at high risk for committing a violent act by young adulthood. In addition, the authors sought to use this screening instrument, in conjunction with child and parent psychopathology and substance abuse data, to determine the accuracy of violent outcome predictions. METHOD: The probands were men with a lifetime history of DSM-III-R substance use disorder (N=38) and men with no adult psychiatric disorder (N=61). Their biological sons were studied at two time points. At age 12-14, the offspring completed a 13-item Violence Proneness Scale, which was derived by using items from the revised Drug Use Screening Inventory. The occurrence of violent acts was then assessed at a follow-up evaluation when the offspring were 19 years of age. RESULTS: Among the offspring, a DSM-III-R axis I psychiatric disorder and a Violence Proneness Scale score of 10 or higher at age 12-14 predicted a violent outcome by age 19. The overall accuracy of prediction was 77%. Sensitivity was 81%, and specificity was 76%. Substance use disorder or psychopathology in the probands or substance use frequency in the children did not contribute to the prediction of violence. CONCLUSIONS: The brief Violence Proneness Scale, which measures school and peer adjustment, in conjunction with a childhood psychiatric history may constitute an efficient screening procedure for identifying youth who are at high risk for committing acts of violence.     

Clinical assessment of the risk of violence among psychiatric inpatients

OBJECTIVE: The authors evaluated the reliability and validity of a probabilistic approach to clinical assessment of short-term risk of violence. METHOD: At admission, nurses and physicians independently rated the probability that each of 149 psychiatric patients would physically attack someone during the first week of hospitalization on a university-based locked inpatient unit. Ward behavior was measured with the Overt Aggression Scale. RESULTS: There was a moderate level of agreement between nurses' and physicians' assessments of risk. Ratings of ward behavior showed an increase in the proportion of assaultive patients as the level of estimated risk of violence increased. Although the overall rate of assaults was overpredicted, there was a close correspondence between clinical estimates of patients' chances of becoming violent and the proportion of patients within each risk level who later displayed some type of inpatient aggression. CONCLUSIONS: The reliability and validity of short-term estimates of the risk of violence among acutely disturbed inpatients may be higher than past violence research has suggested. These findings provide preliminary support for the utility of a probabilistic approach to assessment of the risk of violence.     

Psychological dysfunction in psychiatric and general nurse trainees

The often held belief that psychiatric professionals are more psychologically disturbed than similar non-psychiatric professionals was not supported by the present study. Indeed in a comparison of two groups of nurse trainees, general nurse trainees showed a small but significantly greater degree of psychopathology than psychiatric nurses. When confounding variables and social desirability response set was taken into account, general nurse trainees had significantly higher scores on neuroticism, trait and state anxiety and depression. The groups did not differ on psychoticism (antisocial traits), extraversion, hypochondriasis or, work or social impairment. In terms of use of illicit drugs, the psychiatric nurses used only more cannabis than general nurses which was accounted for by females alone.     

Can prediction of violence among psychiatric inpatients be improved?

In an effort to improve the prediction of violence among psychiatric inpatients, the authors retrospectively studied 25 patients who were violent and 34 who were not violent after admission to a psychiatric emergency ward in Norway. The only demographic variable that discriminated between the two groups was violence in the family of origin; the violent group had experienced significantly more. The best single predictor of violence was a history of previous violence by the patient, which correctly classified 80 percent of the patients. The combined information about patients' level of aggression rated at referral and level of anxiety rated at admission correctly classified 78 percent. In a subgrouping of violent patients who inflicted injuries and did not inflict injuries, a higher percentage of the injury-inflicting patients were found to have a diagnosis of schizophrenia. These patients also had a higher level of aggression at referral.     

Frequency and risk factors of workplace violence on psychiatric nurses and its impact on their quality of life in China

This study examined the frequency of violence on nurses in Chinese psychiatric hospitals and explored its risk factors and impact on nurses' quality of life (QOL). A survey was conducted with 387 frontline psychiatric nurses in China. Information about experience of workplace violence in the past 6 months, type of workplace violence, and demographic characteristics was collected by a questionnaire. Altogether 319 (82.4%) of 387 nurses reported having experienced at least one type of violent event in the past 6 months. The prevalence of sexual assault, physical and verbal harassment was 18.6%, 61.5% and 78.6%, respectively. Compared to those with no exposure to violence, nurses who were exposed to violence had lower QOL in both the physical and mental domains. Significant predictors of violence against nurses are male sex, receiving college level or higher education and working on rotating duty were independently associated with high risk of violence. Workplace violence against psychiatric nurses commonly occurs in China. Considering the deleterious effects of violence, comprehensive strategies from the perspective of nursing education and training, organizational policy, patient care and staff support are recommended to promote occupational safety in psychiatric settings in China.     

Aggression in psychiatry wards: a systematic review

Although fairly frequent in psychiatric in-patient, episodes of aggression/violence are mainly limited to verbal aggression, but the level of general health is significantly lower in nurses who report ‘frequent’ exposure to violent incidents, and there is disagreement between patients and staff concerning predictors of these episodes. We searched the Pubmed, Embase and PsychInfo databases for English, Italian, French or German language papers published between 1 January 1990 and 31 March 2010 using the key words “aggress*” (aggression or aggressive) “violen*” (violence or violent) and “in-patient” or “psychiatric wards”, and the inclusion criterion of an adult population (excluding all studies of selected samples such as a specific psychiatric diagnosis other than psychosis, adolescents or the elderly, men/women only, personality disorders and mental retardation). The variables that were most frequently associated with aggression or violence in the 66 identified studies of unselected psychiatric populations were the existence of previous episodes, the presence of impulsiveness/hostility, a longer period of hospitalisation, non-voluntary admission, and aggressor and victim of the same gender; weaker evidence indicated alcohol/drug misuse, a diagnosis of psychosis, a younger age and the risk of suicide. Alcohol/drug misuse, hostility, paranoid thoughts and acute psychosis were the factors most frequently involved in 12 studies of psychotic patients. Harmony among staff (a good working climate) seems to be more useful in preventing aggression than some of the other strategies used in psychiatric wards, such as the presence of male nurses.     

Hostility during admission interview as a short-term predictor of aggression in acute psychiatric male inpatients

BACKGROUND: A critical step for improving the prediction of on-ward violence is the identification of variables that are not only consistently associated with an increased risk of aggression but also easily evaluated during the admission interview. The goal of this prospective study was to assess the predictive utility of hostility during admission interview. METHOD: The sample consisted of 80 newly admitted male patients with heterogeneous DSM-IV psychiatric diagnoses recruited from the psychiatric ward of an urban public hospital. Psychiatric symptoms at admission were assessed with the Brief Psychiatric Rating Scale (BPRS). Aggressive behavior during the first week of hospitalization was measured with the Modified Overt Aggression Scale. Data were collected between January and June 1998. RESULTS: In a multiple regression model, BPRS items hostility and tension-excitement emerged as significant predictors of verbal aggression, whereas thinking disturbance (high) and suspiciousness-uncooperativeness (low) emerged as significant predictors of aggression against objects. In contrast, when aggression was treated as a binary dependent variable in a logistic model, hostility during the admission interview had no utility in predicting on-ward aggressive behavior. CONCLUSION: This study confirms the importance of distinguishing between different types of aggression to improve the accuracy of predictions of violence. The findings suggest that the question whether hostility is a useful short-term predictor of aggression in psychiatric inpatients cannot be answered conclusively. The predictive utility of hostility was relatively high for predicting verbal aggression but was negligible for predicting other types of aggressive behavior.     

Change in work performance in vocational rehabilitation for people with severe mental illness: distinct responder groups

BACKGROUND: Vocational rehabilitation aims to improve work performance. Few studies have examined the course of work performance during vocational rehabilitation. It remains unclear whether all subjects profit equally from rehabilitation programs regarding improvement of work performance. AIMS: The purpose of this study is to examine the course of work performance in order to differentiate between responder groups and to distinguish between those groups regarding sociodemographic status, psychiatric diagnosis, level of individual satisfaction and vocational rehabilitation success. METHODS: Work performance of N = 125 subjects with severe mental disorders was rated on intake to the rehabilitation program and six months later with the German version of the Work Personality Profile (WPP). A cluster analysis was conducted to identify different responder groups. RESULTS: Groups with poor, moderate, improving and superior work performance were identified. These groups differed in educational level, psychiatric diagnosis, individual satisfaction and rehabilitation outcome. CONCLUSION: Not all subjects profit equally from vocational rehabilitation in terms of improvement of work performance. Unfavorable courses of work skills were shown for participants with schizophrenia and low education. Low individual satisfaction with performance is related to consistently low or moderate performance. Group differences predicted reintegration success. Future research should focus on different responder groups and their identification in early stages of the rehabilitation process to ensure appropriate assistance, particularly for subjects with poorer performance.     

Incidence and clinical correlates of aggression and violence at presentation in patients with first episode psychosis

This study aimed to identify the incidence and clinical correlates of aggression and violence in first episode psychosis. We prospectively recruited subjects with a first episode of DSM-psychosis presenting from a geographically defined catchment area to a secondary referral psychiatric service over a four-year period (n = 157). We used the Modified Overt Aggression Scale to retrospectively assess aggression (a hostile or destructive mental attitude, including verbal aggression, physical aggression and/or violence) and violence (the exercise of physical force), blind to diagnosis. One in three patients with psychosis was aggressive at the time of presentation. One patient in 14 engaged in violence that caused, or was likely to cause, injury to other people. Aggression was independently associated with drug misuse (odds ratio (OR) 2.80, 95% confidence interval 1.12-6.99) and involuntary admission status (OR = 3.62, 95% CI 1.45-9.01). Violence in the week prior to presentation was associated with drug misuse (OR = 2.75, CI 1.04-7.24) and involuntary admission status (OR = 3.21, CI 1.21-8.50). Violence in the week following presentation was associated with poor insight (OR 2.97, CI 1.03-8.56) and pre-contact violence (OR 3,82, CI 1.34-10.88). In patients with schizophrenia, violence in the week following presentation was associated with drug misuse (OR = 7.81, CI 1.33-45.95) and high psychopathology scores (OR = 20.59, CI 1.66-254.96). Overall, despite a high rate of verbal aggression, physical violence towards other people is uncommon in individuals presenting with first episode psychosis.     

A Qualitative Study of Factors Influencing Psychiatric Nursing Practice in Australian Prisons

TOPIC: Factors influencing the practice of psychiatric nursing in Australian prisons. METHODS: A qualitative study of psychiatric nurses (N = 30) working in a prison. FINDINGS: The psychiatric nurses identified the following factors as influencing their work: challenging patients, threats to personal survival of patients, the technology and artifice of confinement, conflicting values of nurses and corrections staff, stigma by association, and prisoner identification of the nurses with prison administration. CONCLUSIONS: Psychiatric nurses who work in forensic settings must adapt to less than optimal practice conditions.     

More than zero tolerance? Burnout and tolerance for patient aggression amongst mental health nurses in China and the UK

OBJECTIVE: The aim of the study was to examine attitudes toward patient aggressive behaviour amongst mental health nurses in China and the UK and the relationship between these attitudes and burnout. The UK government policy of 'zero tolerance' of patient aggression may conflict with practitioner attitudes and could potentially increase the risk of aggression occurring. METHOD: Two surveys of mental health nurses were conducted, one in the People's Republic of China and one in the UK using the Perceptions of Aggression Scale (POAS). The UK sample also completed the Maslach Burnout Inventory (MBI). RESULTS: Some nurses in both groups agreed that patient aggression could sometimes have positive benefits. A sense of personal accomplishment at work (MBI) was significantly associated with a tendency to endorse positive statements about aggression. DISCUSSION: Nurses seem to have a complex set of attitudes toward this issue that do not simply equate with 'zero tolerance'.     

The clinical presentation of command hallucinations in a forensic population

In a forensic population, patients with command hallucinations (N = 25) were compared to two groups of psychotic patients: those with noncommand hallucinations (N = 24) and those without hallucinations (N = 16). The three groups did not differ in overall impairment as measured by the Global Assessment Scale and the Social Behavior Rating Schedule. However, the group with command hallucinations differed in the content of their hallucinations (more aggression, dependency, and self-punishment themes), and nearly one-half did not report or denied their command hallucinations to the assessment team. Many patients (N = 11, 44%) reported that they frequently responded to hallucinatory commands with unquestioning obedience.     

Prevalence of antithyroid antibodies in mood disorders

We examined the prevalence of antimicrosomal and antithyroglobulin antibodies in psychiatric inpatients with unipolar depression (N = 218), bipolar disorder manic (N = 51), bipolar disorder depressed (N = 19), and bipolar disorder mixed (N = 26) in comparison with two control groups: psychiatric inpatients with adjustment disorder (N = 80) and family medicine outpatients without current psychiatric illness (N = 144). A statistical analysis that controlled for age and sex revealed the frequency of positive antibody titers not to be increased in patients with a diagnosis of unipolar depression (6.9%) or bipolar disorder manic (3.9%), when compared with patients with adjustment disorder (2.5%) and non-psychiatric subjects (6.9%). There was a weak trend toward an increased prevalence of antithyroid antibodies in patients with bipolar disorder, mixed (19%) or depressed subtype (16%). The excess occurrence of antibodies in patients with either mixed or depressed bipolar disorder did not appear to be related to lithium exposure, which was similar in all bipolar subgroups. When the intervening influences of age and sex are taken into account, unipolar depression does not appear to be associated with an excessive rate of antithyroid antibodies; however thyroid autoimmunity may be weakly associated with subtypes of bipolar disorder in which depressive symptoms are prominent. Depression and Anxiety 5:91–96, 1997. © 1997 Wiley-Liss, Inc     

Occupation and social experience: Factors influencing attitude towards people with schizophrenia

The purpose of the present study was to examine the role of occupation and social experience as factors determining the attitude of psychiatric care workers and other workers from various backgrounds toward people with schizophrenia. To measure the attitude of 786 subjects from six occupational groups toward people with schizophrenia, the evaluation scale applying semantic differential technique and the modified Social Rejection Scale were used, which assess two aspects of the attitude: affective acceptance and social distancing, respectively. The results of the two scales from the six groups were similar on the whole. Public health nurses showed the most accepting attitude in both scales. Psychiatric nurses and local welfare commissioners were the second and the third groups in affective acceptance, and the third and the second in socially accepting behavior, respectively. There was no significant difference in attitude among the rest of the groups (non-psychiatric care workers, professional probation officers and non-care workers). These results can be understood in terms of the workers' experience of contact with people with schizophrenia, and education and other support opportunities. The importance of positive contact experiences and the means for facilitation of an accepting attitude in psychiatric care workers and other workers need to be stressed.     

Predictors of violent behavior among acute psychiatric patients: clinical study

Aim:  Violence risk prediction is a priority issue for clinicians working with mentally disordered offenders . The aim of the present study was to determine violence risk factors in acute psychiatric inpatients.
Methods:  The study was conducted in a locked, short-term psychiatric inpatient unit and involved 374 patients consecutively admitted in a 1-year period. Sociodemographic and clinical data were obtained through a review of the medical records and patient interviews. Psychiatric symptoms at admission were assessed using the Brief Psychiatric Rating Scale (BPRS). Psychiatric diagnosis was formulated using the Structured Clinical Interview for DSM-IV. Past aggressive behavior was evaluated by interviewing patients, caregivers or other collateral informants. Aggressive behaviors in the ward were assessed using the Overt Aggression Scale. Patients who perpetrated verbal and against-object aggression or physical aggression in the month before admission were compared to non-aggressive patients, moreover, aggressive behavior during hospitalization and persistence of physical violence after admission were evaluated.
Results:  Violent behavior in the month before admission was associated with male sex, substance abuse and positive symptoms. The most significant risk factor for physical violence was a past history of physically aggressive behavior. The persistent physical assaultiveness before and during hospitalization was related to higher BPRS total scores and to more severe thought disturbances. Higher levels of hostility–suspiciousness BPRS scores predicted a change for the worse in violent behavior, from verbal to physical.
Conclusion:  A comprehensive evaluation of the history of past aggressive behavior and psychopathological variables has important implications for the prediction of violence in psychiatric settings.     

Evaluation of the Perception of Aggression Scale (POAS) in Swedish nurses

Even though much is known about individual risk factors for institutional violence, large variations in frequency between institutions still remain unexplained. Staff attitudes have been pointed out as a possible important and explaining factor. The Perception of Aggression Scale (POAS) is a newly developed attitude inventory assessing nurses' attitudes toward aggressive patients. The aims of this study are to evaluate the factor structure of the Swedish version of the POAS and to evaluate its discriminatory capacity in different groups of nurses. The shortened POAS was handed out to 357 nurses at 12 different psychiatric wards in Sweden. Responses were analysed with exploratory principal component factor analysis. The emerging factors were correlated in a rank-transformed multiple regression analysis to individual characteristics of each nurse. The factor analyses revealed exactly the same factor structure in this Swedish sample of nurses as in previous German and Dutch studies. When expanding the factor analysis, a three-factor solution emerged. It was also found that the factor "Aggression as a protective measure" was correlated to age and experience of aggression management training while the factor "Aggression as dysfunctional/undesirable phenomenon" was sensitive for gender. The shortened 12-item POAS contains three discrete dimensions and thus seems to be a solid tool for evaluating attitudes towards violence. Of special interest is the possibility that the factor "Aggression as a protective measure" could be sensitive to training. Further studies should correlate dimensions of staff attitudes to the occurrence of inpatient violence.     

Nadolol to treat aggression and psychiatric symptomatology in chronic psychiatric inpatients: a double-blind, placebo-controlled study.

BACKGROUND: Considerable evidence indicates that the lipophilic beta-blocker propranolol is useful in treating organically based aggression. This study looked at the efficacy of a more hydrophilic beta-blocker, nadolol, to treat aggression in chronic psychiatric inpatients. METHOD: Forty-one chronic psychiatric inpatients with an average of one aggressive outburst per week (defined by the Overt Aggression Scale [OAS]) were entered into a double-blind, placebo-controlled study lasting 17 weeks. The OAS was used to track aggression on a per-incident basis, while the Brief Psychiatric Rating Scale (BPRS) and the Clinical Global Impressions scale (CGI) were used to track clinical status. RESULTS: Nadolol subjects showed a significant decline in frequency of aggression compared with controls (p = .026) and a significant decline in the BPRS total score (p = .007) and in the subfactors "hostility and suspicion," "negative symptoms," and "signs of hyperarousal/tension." There was no significant change in CGI "severity of illness" ratings between groups, although the nadolol group was significantly improved from baseline at every subsequent time period while the placebo group was unchanged throughout the study. CONCLUSION: Nadolol is of significant benefit in the treatment of aggression in chronic psychiatric inpatients. This drug does penetrate the brain over time, but the success of a drug whose primary locus of action is peripheral may implicate a bimodal mechanism of action, i.e., a role for the CNS and the soma in the maintenance of aggression.     

Sticks, stones, and hurtful words: relative effects of various forms of childhood maltreatment

OBJECTIVE: Childhood maltreatment is an important psychiatric risk factor. Research has focused primarily on the effects of physical abuse, sexual abuse, or witnessing domestic violence. Parental verbal aggression has received little attention as a specific form of abuse. This study was designed to delineate the impact of parental verbal aggression, witnessing domestic violence, physical abuse, and sexual abuse, by themselves and in combination, on psychiatric symptoms. METHOD: Symptoms and exposure ratings were collected from 554 subjects 18-22 years of age (68% female) who responded to advertisements. The Verbal Abuse Questionnaire was used to assess exposure to parental verbal aggression. Outcome measures included dissociation and symptoms of "limbic irritability," depression, anxiety, and anger-hostility. Comparisons were made by using effect sizes. RESULTS: Verbal aggression was associated with moderate to large effects, comparable to those associated with witnessing domestic violence or nonfamilial sexual abuse and larger than those associated with familial physical abuse. Exposure to multiple forms of maltreatment had an effect size that was often greater than the component sum. Combined exposure to verbal abuse and witnessing domestic violence had a greater negative effect on some measures than exposure to familial sexual abuse. CONCLUSIONS: Parental verbal aggression was a potent form of maltreatment. Exposure to multiple forms of abuse was associated with very large effect sizes. Most maltreated children had been exposed to multiple types of abuse, and the number of different types is a critically important factor.     

Elevated serum levels of C-reactive protein are associated with mania symptoms in outpatients with bipolar disorder

OBJECTIVES: We investigated the association between serum levels of C-reactive protein (CRP), a marker of inflammation, and the severity of psychopathology in outpatients with bipolar disorder. We also compared the levels of CRP in the bipolar disorder individuals with those of a non-psychiatric control group. METHODS: We measured the level of CRP in N=122 outpatients with bipolar disorder and N=165 control individuals and evaluated the symptom severity of the bipolar disorder patients with the Young Mania Rating Scale (YMRS) and the Hamilton Depression Scale (Ham-D). RESULTS: Within the bipolar disorder sample, CRP was significantly associated with the YMRS score (r=.306, p<.006), age of onset, gender, and race. CRP was not significantly associated with the Ham-D score or other clinical or demographic variables. In a multivariate analysis of covariance, CRP was the only independent predictor of YMRS score (F=11.7, p=.0009). The CRP levels of the n=41 individuals with YMRS >6 were significantly greater than the levels of the n=81 individuals with YMRS 6 were also significantly greater than the levels of the control group (p=.033) while the CRP levels of the group with YMRS .05). CONCLUSIONS: Our results suggest that outpatients with bipolar disorder with mania symptoms have increased levels of CRP as compared to those without mania symptoms and compared to individuals without psychiatric disorders. The long-term consequences of CRP in bipolar disorder should be the subject of future studies.