Aggression on the psychiatric ward: Prevalence and risk factors. A systematic review of the literature

Abstract

Introduction On psychiatric wards, aggressive behaviour displayed by patients is common and problematic. Understanding factors associated with the development of aggression offers possibilities for prevention and targeted interventions. This review discusses factors that contribute to the development of aggression on psychiatric wards. Method In Pubmed and Embase, a search was performed aimed at: prevalence data, ward characteristics, patient and staff factors that are associated with aggressive behaviour and from this search 146 studies were included. Results The prevalence of aggressive behaviour on psychiatric wards varied (8–76%). Explanatory factors of aggressive behaviour were subdivided into patient, staff and ward factors. Patient risk factors were diagnosis of psychotic disorder or bipolar disorder, substance abuse, a history of aggression, younger age. Staff risk factors included male gender, unqualified or temporary staff, job strain, dissatisfaction with the job or management, burn-out and quality of the interaction between patients and staff. Staff protective factors were a good functioning team, good leadership and being involved in treatment decisions. Significant ward risk factors were a higher bed occupancy, busy places on the ward, walking rounds, an unsafe environment, a restrictive environment, lack of structure in the day, smoking and lack of privacy. Conclusion Despite a lack of prospective quantitative data, results did show that aggression arises from a combination of patient factors, staff factors and ward factors. Patient factors were studied most often, however, besides treatment, offering the least possibilities in prevention of aggression development. Future studies should focus more on the earlier stages of aggression such as agitation and on factors that are better suited for preventing aggression such as ward and staff factors. Management and clinicians could adapt staffing and ward in line with these results.

Perceptions of patient aggression in psychiatric hospitals: a qualitative study using focus groups with nurses, patients, and informal caregivers

“…All three groups in our study including patients shared the same understanding of aggression. The description of what happened, what types of aggressive events occurred (physical, verbal, threat) and what was the target of the aggressive events (other people, objects, patients themselves) are all in line with definitions of aggressive events in international literature [ 5 – 7 ]. All stakeholder groups also agreed that any action or intention of aggression aimed to harm something or someone.…”

“…It can be conceptualized as reactive (a response to perceived threat that is impulsive and emotionally charged) or proactive (premeditated and controlled) [ 6 ]. It can also be understood as a continuum of severity, where agitation evolves into aggression and ultimately into violence [ 7 ].…”

“…Typically, patient aggression in psychiatric hospitals is described using quantitative approaches regarding prevalence or associated risk factors [ 6 ] including sex, age, comorbid psychiatric disorders, socioeconomic status, and history of aggressive behavior [ 9 ]. Staff related and environmental risks factors for aggression have also been identified using quantitative methods [ 7 ]. Current explanation of reasons for aggression is a combination of factors embodied in patients, staff and the ward environment [ 7 ].…”

“…Staff related and environmental risks factors for aggression have also been identified using quantitative methods [ 7 ]. Current explanation of reasons for aggression is a combination of factors embodied in patients, staff and the ward environment [ 7 ]. On the other hand, aggressive inpatient incidents have not been adequately explained in research [ 10 ].…”

Triggers of Agitation in Psychiatric Hospitalization Ward According to Professional Experience Questionnaire

“…Agitation can also be incited by a combination of factors including patient, staff, and ward factors. [ 26 , 27 , 28 , 29 , 30 ].…”