Inpatient Violence and Aggression: A Literature Review

Inpatient violence and
aggression: a literature
review
Report from the Conflict and Containment

Reduction Research Programme
Len Bowers
Duncan Stewart
Chris Papadopoulos
Charlotte Dack
Jamie Ross
Husnara Khanom
Debra Jeffery
May 2011
Section of Mental Health Nursing
Health Service and Population Research
Institute of Psychiatry
Kings College London
1. BACKGROUND
Mentally ill people in hospital sometimes behave aggressively. They may try to harm
other patients, staff, property or themselves. In the UK, the National Audit of
Violence found that a third of inpatients had been treatened or made to feel unsafe
while in care [Royal College of Psychiatrists 2007]. This figure rose to 44% for
clinical staff and 72% of nursing staff working in these units. Such aggression can
result in injuries, sometimes severe, to patients or to staff, causing staff absence and
hampering the efficiency of the psychiatric service. The ways in which aggressive
behaviour is managed by staff is contentious and emotive, and there is little evidence
or agreement about their effectiveness. This review aims to describe the available
research literature on the prevalence, antecedents, consequences and circumstances of
violence and aggression in psychiatric hospitals.
Our previous research has focussed on how to reduce of conflict and containment on
acute wards. By conflict we mean those things that threaten patient and staff safety,
such as aggression, rule breaking, drug/alcohol use, absconding, medication refusal,
self-harm/suicide etc. By containment we mean those things the staff do to prevent
these things occurring, or reduce the amount of harm that occurs, such as giving extra
medication, intermittent observation, constant observation, show of force, manual
restraint, coerced injections of medication, seclusion, time out, locking of the ward
door, and other security policies. This research indicates a complicated relationship
between conflict behaviours and containment, and that the behaviour and attitudes of
staff may influence both. It led to the development of the City model describing the
ways in which staff factors can reduce rates of conflict and containment on wards.
Three processes are posited to create low conflict and containment: positive
appreciation of patients (kindness), emotional self-regulation of anger and fear
(tranquillity), and an effective structure of rules and routines for patients based upon
an ethical (not punitive) stance (orderliness). In addition to an analysis of the research
literature, therefore, each chapter considers the evidence for and against the City
Model and suggests lessons for future research.
2. LITERATURE SEARCH
Electronic searches of the main databases were conducted to locate studies of
psychiatric inpatient aggression published in English between 1960 and 2009.
Searches were conducted using the following databases: MEDLINE, PsychInfo,
Cochrane Clinical Trials, EMBASE Psychiatry, CINAHL and DARE and the
following keywords: (psychiat* or mental*) and (hospital or ward or inpatient or in-
patient) and (aggressi* or violen*). No attempt was made to search for unpublished
results. 4,353 references were identified. Papers from adolescent and geriatric
services were excluded. Resulting titles and abstracts were then inspected for
relevance. As the literature accumulated, further references were obtained by
following up citations.
A total of 997 hardcopy references were obtained. These were divided between five
researchers for detailed review and data extraction. Under the supervision of the lead
author, the researchers inspected the papers for relevance, eligibility and suitable
empirical data (quantitative or qualitative) which could be used for the review. The
final number of studies included in the review was 424.
A matrix (in Excel) was constructed with a number of headings including:

methodology, sample, definitions and setting used in the article; the patient profiles
(age, gender, ethnicity, diagnosis, treatment, marital status, family circumstances,
previous psychiatric history, etc); the rates of occurrence; times and places or
occurrence of the event; circumstances of event; antecedents and causes; relationships
between types of adverse events; patient motivations; staff related factors and
limitations. Each of the 424 articles was reviewed and analysed by extracting
data/evidence for the relevant sections in the matrix. Additional information not
directly fitting in the predefined categories, was collated in an other findings column
and processed separately.
Definitions were provided for each item on the matrix to facilitate consistency of data
extraction. The initial ten matrix entries for each researcher were cross checked for
accuracy and correct interpretation by the lead author and another team member.
Direct feedback was provided and emerging issues or problems discussed among the
team. Progress with the data extraction phase of the review was monitored by regular
individual and group meetings for a period of six months. Having extracted data onto
the matrix, responsibility for analysis and write-up of specific sections of the review
was divided among the team. This phase of the review took five months to complete.
Written reports for each section were submitted to the lead author for feedback,
revisions and final editing, before being combined into a single document.
3. THE INCIDENCE OF VIOLENCE AND AGGRESSION
3.1 The studies reviewed

At least one measure of the rate of aggression or violence could be calculated for 128
papers. In some cases data had been extracted from multiple publications which
shared the same source data. These studies were only counted once in the analyses.
One Canadian study of treatment resistant patients reported an event based rate of
3696% [Ehmann et al. 2001] which was substantially higher than any other study, so
was excluded from further analysis as an extreme outlier. One study reported rates
from three European cities (London, Modena and Athens)[Bowers et al. 2005]. The
London data from this study was also reported elsewhere [Bowers et al. 2003], but
data for the other two cities are analysed separately. The final sample was 122
studies. Sixty-seven of the studies (55%) were retrospective analyses of official
incident records and/or patient notes, while 55 (45%) used descriptive data from other
sources such as surveys, interviews and observation recording instruments designed
for the study. Thirty-eight were case-control studies and six were classified as before
and after studies.
The studies were conducted in various types of setting, ranging from acute wards
(n=37, 30%), forensic units (n=36, 30%) to psychiatric hospitals with a mix of ward
types (n=40, 33%). In nine (7%) cases the type of ward was classified as other.
Most studies were conducted in the USA (n=35, 29%) or UK (n=31, 26%). Other
countries represented included Australia (n=14, 12%), Norway (n=6, 5%), Canada
(n=5, 4%), Netherlands (n=5, 4%), Sweden (n=4, 3%), Italy (n=4, 3%), Germany
(n=2, 2%), Israel (n=2, 2%) and Taiwan (n=2, 2%). The studies involved a total of
69,249 patients, with an average sample of 581.9 (SD=1,035.1) per patient-based
study.
The definition of violence and aggression differed widely between studies. Types of
violence recorded included physical violence, physical violence directed at staff only,
verbal aggression, aggression towards objects, self-harm and sexual aggression.
Almost all the studies included physical violence, but the inclusion of the other
categories of violence and aggression varied. Where patients were responsible for
more than one category of violence studies typically only recorded the most serious
incident. These complexities meant that the review could not accurately describe
rates for individual categories of violence.
3.2 Overall incidence

The incidence of violence was calculated for seven types of measure: patient based %
(violent patients/sample*100), event based % (incidents/sample*100); events per 100
admissions per month (incidents per month/admissions per month*100); patients per
100 admissions per month (violent patients per month/admissions per month*100);
events per 100 occupied bed days (incidents/total patient bed days*100); patients per
100 occupied bed days (violent patients/total patient bed days*100); and events per
100k population per year. The overall mean incidence of violence across all the
studies was as follows: 32.4% (SD=19.6) of patients, 224.8 (SD=378.8) event based
percentage, 182.8 (SD=366.8) events per 100 admissions per month, 26.2 (SD=18.0)
patients per 100 admissions per month, 3.14 (SD=5.4) events per 100 occupied bed
days, 0.42 (SD=0.32) patients per 100 occupied bed days, and 122.2 (SD=138.6)
events per 100k population per year.
A meta-analysis (with random effects) was conducted as an alternative method of

calculating an overall rate of violence. This has the advantage of taking sample sizes
into account. The analysis showed a combined rate of 30.7% (95% CI=28.4-33.0).
However, the I-squared measure of heterogeneity was 98.7%, substantially higher
than the 50% recommended as an indicator that combining studies for meta-analysis
may be invalid [Perera & Heneghan 2008].
Kernel density plots show that the distribution of each variable was not normally
distributed (Figures 1 to 6), with event based rates showing greater positive skew than
patient based rates. For the purposes of statistical analysis in this report, patient and
event rates were square root and log transformed respectively to reduce the influence
of extreme scores.
Figure 1: Distribution for patient based rate

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kernel = epanechnikov, bandwidth = 7.1065
Figure 2: Distribution of event based rate
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Figure 3: Distribution of events per 100 admissions per month

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Figure 4: Distribution of patients per 100 admissions per month
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Figure 5: Distribution of events per 100 occupied bed days

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Figure 6: Distribution of patients per 100 occupied bed days
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3.3 Incidence by country and setting
Mean rates were calculated for countries and settings with at least two studies for each
type of measure (Table 1). Unfortunately, there was insufficient data to enable
comparable analysis of rates per 100 occupied bed days or per 100k population.
Countries were also ranked for each measure (Table 2).
Table 1: Mean violence rates by country and measure
Events per
100 Patients per Events per Patients per
Patient Event adms per 100 adms per 100 occ bed 100 occ bed
Country based % based % month month days days
Australia 36.85 150.72 109.67 31.58 9.09 0.63
Canada 32.61 81.46 36.27 18.77 0.70 0.40
Germany 16.06
Israel 16.73
Italy 20.28 27.47 8.99 8.21
Netherlands 24.99 186.69 220.21 31.79 3.50 0.56
Norway 33.47 471.85 460.78 32.47 10.19
Sweden 42.90 59.25
Taiwan 128.27
United
Kingdom 41.73 303.49 170.73 32.97 2.25 0.35
Unites States 31.92 341.87 302.47 16.92 0.16 0.14
Analysis using one way ANOVAs showed that none of the comparisons were
statistically significant. However, the highest proportion of violent patients was
found in Sweden, the UK and Australia. The lowest patient based rates were from
Germany, Israel and Italy. Despite having the highest proportion of patients involved
in violence Sweden had one of the lowest event based rates, suggesting that violent
patients in that country commit fewer violent acts than in others. The UK remained
one of the countries with the highest event based rate, but while the USA had the
second highest rate for this measure, it was sixth out of ten for patient based rates.
The highest event based rate was for Norway, but this were influenced by one
forensic study with a high level of violence (2069%)[Rasmussen and Levander 1996],
although the study only measured physical violence towards staff in a forensic unit.
Without this study the mean event based rate for Norway was 58.69, which was one
of the lowest rates and comparable to Sweden. Italy had the fewest violent patients
and events among the countries which had data available for both these measures.
When rates were standardised by the number of admissions per month, the proportion
of patients involved in violence was highest for Australia, UK, Norway and the
Netherlands. Around a third of patients per 100 admissions from these countries had
committed at least one violent act. Greater differentiation was apparent for
standardised event based rates. Again Norway had the highest event based rate,
reflecting the outlier in this country. The USA had the next highest rate followed by
the Netherlands and UK. A mean rate per 100 occupied bed days could be calculated
for only six countries. Nevertheless, Australia and Norway had by far the highest
event based results for this measure (this time the outlier study from Norway could
not be included in the calculations). Canada and the USA had the lowest rates.
Norway and Australia also had the highest patient based rate per 100 occupied bed
days, and the UK and US the lowest. International comparisons across these different
measures needs to be interpreted cautiously because the same studies did not
contribute to each average score, the proportion of studies from different settings
differed between the countries, the definition of violence varied and the number of
studies from some countries was small.
Table 2: Ranked mean violence rates by country (high to low)

Events per
100 Patients per Events per Patients per
Patient Event adms per 100 adms per 100 occ bed 100 occ bed
based % based % month month days days
Australia 3 5 5 1 2 1
Canada 5 7 6 5 5 3
Germany 10
Israel 9
Italy 8 9 7 7
Netherlands 7 4 3 4 3 2
Norway 4 1 1 3 1
Sweden 1 8
Taiwan 6
United
Kingdom 2 3 4 2 4 4
Unites States 6 2 2 6 6 5
Rates of violence would also be expected to be influenced by the type of psychiatric

service patients were recruited from. In particular, patients treated in forensic settings
are likely to be more violent than those from other settings, not least because the
majority are admitted specifically because of their violent behaviour [Coid et al.,
2001]. This was confirmed by statistical comparison of rates reported by studies
from forensic, acute and psychiatric hospital settings (Table 3). Nine studies which
could not be classified into these three categories were excluded from the analysis.
Mean rates for studies of forensic inpatient services were consistently higher than
those from an acute ward setting, except for rates per 100 occupied bed days. Raw
patient and event based percentages1 and those per 100 admissions were also
significantly higher in studies of forensic hospitals than those of whole psychiatric
hospitals (including a mix of ward types). There was an overall difference between
groups for patients per 100 occupied bed days, with a significant difference between
forensic and acute wards.
Table 3: Rates of violence by setting

Measure Acute Forensic Psych hosp F df p
Mean SD Mean SD Mean SD
a a,b b
Patient based rate 26.18 15.07 47.71 18.76 22.08 14.33 21.60 2,87 0.000
a a,b b
Event based rate 71.56 64.93 411.31 516.08 120.537 253.87 9.37 2,71 0.000
a a,b b
Events per 100 adms 48.89 53.95 406.09 542.89 38.77 46.05 12.01 2,39 0.000
a a,b b
Patients per 100 adms 20.14 12.27 45.65 14.11 12.41 7.76 20.25 2,35 0.000
Events per 100 occ beds 4.02 4.69 0.94 1.20 5.77 11.15 1.59 2,19 0.230
a a
Patients per 100 occ beds 0.63 0.26 0.28 0.30 0.15 0.04 4.83 2,16 0.023
1
A meta-analysis showed a similar trend, with a higher overall rate for forensic studies (45.8%, 39.6-
51.9) compared to acute wards (25.6%, 21.2-30.0) and psychiatric hospitals (20.8%, 18.0-23.6).
Again, however, I-squared values were above 90% for each setting.
Note: Means on the same row and sharing the same superscript letter differ
significantly by p<0.05 (Scheffe test).
Standardising measures by bed occupancy countered the trend indicated by basic rates
or rates standardised by admissions. There were 26 studies which provided data to
enable calculation rates per 100 occupied bed days (20 for patients, 24 for events), but
there was no statistically significant difference between these and the remainder of
studies in terms of setting (2[3] =4.67, p=0.197), methodology (2[1] =0.32 p=0.570) or
definition (,2[3] =2.39, p=0.495).
The different results for occupancy based rates are likely to reflect insensitivity of this
measure to patient throughput. The mean sample size for the forensic studies (152.8,
SD=154.8) was significantly smaller than the studies from acute wards (632.4,
SD=1088.0) and psychiatric hospitals (999.3, SD=1349.7)(F[2,107]=13.29, p=0.000).
This would have provided forensic studies with a lower denominator for calculation
of admissions based rates. However, the impact of a smaller sample on occupancy
based rates was probably offset by a longer study period for forensic studies. The
mean timeframe (in months) was 31.3 (SD=41.0) compared to 18.7 in acute services
and 15.6 (SD=18.8) in psychiatric hospitals. This difference was statistically
significant (F[2,106]=4.29, p=0.016), with a post-hoc Scheffe test indicating that
forensic and acute ward studies differed significantly (p<0.05). These statistical
comparisons of sample size and months were conducted with log transformed
variables.
Further (non-statistical) analysis was conducted to compare rates across both country
and setting (Figures 7 to 10). In all countries with available data patient based
percentages showed forensic services to have the highest rates of violence. Rates
among forensic patients were highest in the UK and US and lowest in Australia,
although the rate in all countries was over 40%. A similar pattern was found for acute
patients, with the highest rates found for the UK, US and Netherlands and the lowest
in Australia. However, a greater proportion of violent patients reported by studies of
whole psychiatric hospitals were found in Australia, compared to the US and UK.
Event based percentages were greatly higher in forensic studies from the UK and
USA. Among the Australian studies the rate for forensic patients was much lower,
and almost equal to the rate for psychiatric hospitals. The rate for acute patients was
highest in the Netherlands.
Fewer studies were available for comparisons of rates per 100 admissions. Only the
UK had data available for both patient and event based rates and for each setting. As
expected, the UK rates were much higher for studies of forensic patients, but there
was greater differentiation between acute and general psychiatric hospitals for patient
than event based rates per 100 admissions. The UK also had the highest rates for
forensic studies compared to other countries. Australia had the lowest patient based
rates for both forensic and acute studies. Patient and event based rates for acute
services were highest in the Netherlands.
Figure 7: Mean patient based % by country and setting
60
50
40
% 30
20
10
0
UK USA AUS CAN NOR NL IT DE
Forensic Acute Psych hosp
Figure 8: Mean event based % by country and setting
900
800
700
600
500
%
400
300
200
100
0
UK USA AUS CAN NOR NL IT
Figure 9: Mean events per 100 admissions per month
500
400
300
%
200
100
0
UK USA AUS NOR NL

Figure 10: Mean patients per 100 admissions per month
60
50
40
% 30
20
10
0
UK USA AUS NOR NL

3.4 Definition
The influence of definition on overall rates was tested as follows. The studies were
classified by whether they included verbal aggression, physical violence, aggression
towards objects and self-harm. Occasionally studies also included sexual aggression.
The number of studies which measured each type of violence is shown in Table 4.
The most common combinations were: verbal, physical, towards objects & self-harm;
physical only; verbal, physical & towards objects. All the studies which defined
violence or aggression (n=121) included physical violence, although in six studies this
was against staff only. Fifty-nine percent of studies included verbal aggression and
36% included self-harm.
Table 4: Definitions of violence/aggression

Type of aggression N %
Physical only 26 21.3
Physical only directed at staff 6 4.9
Physical & towards objects 8 6.6
Physical, towards objects & self-harm 5 4.1
Physical & self-harm 4 3.3
Verbal & physical 8 6.6
Verbal, physical & sexual 2 1.6
Verbal, physical & towards objects 26 21.3
Verbal, physical, towards objects & sexual 2 1.6
Verbal, physical, towards objects & self-harm 30 24.6
Verbal, physical & self-harm 4 3.3
Not defined 1 0.8
The frequencies enabled four groups of studies to be compared: physical aggression,

verbal, physical and towards objects, verbal, physical, towards objects and self-harm,
and the remainder of studies (Table 5).
Table 5: Rates of violence by definition

Verbal, Verbal,
physical physical,
Measure Physical & objects objects & self Other F P
Mean SD Mean SD Mean SD Mean SD
Patient based rate 24.93 14.43 37.67 20.39 38.55 23.98 31.80 18.38 2.31 0.081
Event based rate 217.98 513.99 239.48 399.19 302.81 399.68 142.20 182.29 0.95 0.420
Events per 100 adms 269.45 675.83 103.19 76.99 231.46 336.3 146.08 238.85 0.29 0.831
Patients per 100 adms 25.46 16.16 31.08 16.73 21.44 18.05 24.52 22.55 0.59 0.625
a,b,c a b c
Events per 100 occ beds 10.83 5.58 0.71 0.64 1.55 2.23 1.91 2.27 4.63 0.014
Patients per 100 occ beds 0.63 0.04 0.38 0.35 0.54 0.34 0.21 0.22 1.54 0.242
Note: Means on the same row and sharing the same superscript letter differ
significantly by p<0.05 (Scheffe test).
The standard deviations indicate large variations in rates within the groups, but there
were no statistically significant difference for patient based rates, event based rates,
events per 100 admissions or patients per 100 admissions. However, studies of
physical violence had higher event rates per 100 occupied be days than other
categories of study.
Studies were then classified by whether or not they included verbal aggression. Each
measure of violence was then compared between the verbal (n=72) and non-verbal
(n=49) aggression groups (Table 6). The results show only one statistically
significant difference: patient based rates were higher when verbal aggression was
included in the definition of violence.
Table 6: Rates of violence by inclusion/exclusion of verbal aggression

Without verbal
Measure aggression With verbal aggression t p
Mean SD Mean SD
Patient based % 27.22 15.74 36.80 21.47 2.28 0.025
Event based % 191.30 400.82 240.72 361.97 1.37 0.175
Events per 100 adms 206.19 533.82 170.23 247.16 1.33 0.192
Patients per 100 adms 22.26 15.95 28.19 20.35 0.96 0.345
Events per 100 occ beds 4.66 6.30 1.64 2.07 1.135 0.269
Patients per 100 occ beds 0.34 0.26 0.45 0.34 0.611 0.549
3.5 Study methodology

Sixty-seven of the studies (55%) collected incident data from official hospital records
or nursing notes while 55 (45%) were observation studies (typically using SOAS or a
similar instrument). Rates by these two methodologies were compared (Table 7).
There were no significant differences for the patient based rate, event based rate,
events per 100 admissions, patients per 100 admission or events per 100 occupied
beds. However, observational studies had a significantly higher rate for patients per
100 occupied beds.
Table 7: Rates by methodology

Measure Official records Observational t p
Mean SD Mean SD
Patient based rate 32.15 19.76 33.20 19.78 0.33 0.743
Event based rate 264.78 462.42 180.57 254.10 0.01 0.994
Events per 100 adms 213.01 433.17 131.72 217.03 0.78 0.441
Patients per 100 adms 28.90 20.48 22.40 13.71 0.35 0.726
Events per 100 occ beds 4.01 7.17 2.27 2.60 0.01 0.995
Patients per 100 occ beds 0.20 0.21 0.60 0.28 3.58 0.002
3.6 Trends over time
Studies were ordered by date of data collection. Where studies were conducted over
two years the most recent was chosen for the purposes of the analysis. For studies
covering more than two years, the midpoint was selected. However, no discernable
trends over time were identified.
3.7 Repeated violence

The studies commonly reported that a small sub-group of patients were responsible
for the majority incidents. This was expressed a variety of ways: different proportions
of patients were reported to account for different proportions of incidents. The lack of
consistency in reporting makes it impossible to compare or aggregate across
individual studies.
Thirty-one studies provided enough information to calculate the proportion of violent

patients who were involved in repeated incidents. This figure ranged from 12% to
81%, with a mean of 44.7% (SD=16.8). Studies from Australia (n=3) recorded a
higher rate (59.9, SD=20.4) than the UK (41.2, SD=11.4) and USA (35.6, SD=21.1).
Forensic studies reported a higher rate (54.0, SD=17.1) than those from acute settings
(44.9, SD=17.9) and psychiatric hospitals (36.6, SD=12.6).
The papers were examined for information allowing the calculation of a mean rate of
violence per violent patient. This repeat rate was available for 65 studies. However,
the analysis excludes one outlier study from Norway (mean incidents per violent
patient=37.4), leaving a final sample of 64 for this section. The number of incidents
per violent patient ranged from 1 to 21.1, with an overall mean of 4.2 (SD=3.6). A
kernel density plot indicated that the variable was positively skewed and was log
transformed for the purposes of statistical analysis.
Figure 11: Distribution of repeated violence
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Countries with at least two studies reporting repeated violence were compared (Figure
5). Individual studies with high rates of repeated violence were found in Norway, UK
and USA. Averages across countries ranged from: Canada (2.3, SD=1.4), Italy (2.3,
SD=0.7), Taiwan (2.6, SD=0.5), UK (4.2, SD=3.5), Netherlands (4.3, SD=2.6), USA
(4.4, SD=4.0). Australia (4.6, SD=1.5 and Norway (5.0, SD=4.4). However, a
statistical comparison did not reach significance (F[7,45]=0.82, p=0.579).
Repeated violence was also examined across settings (Figure 6). The mean rate was
highest for forensic studies (5.4, SD=4.9), compared to acute wards (3.0, SD=2.1) and
psychiatric hospitals (3.9, SD=2.8). This difference was not statistically significant
(F[2,57]=1.76, p=0.181).
As with rates of violence, studies were categorised into four groups based upon the
definition of violence employed (n=64). The mean rate of repeated violence for
studies of physical aggression was 5.6 (SD=9.1), 4.1 (SD=2.5) for studies of verbal,
physical and aggression towards objects, 4.1 (SD=4.0) for studies verbal, physical,
self-harm and aggression towards objects and self-harm, and 4.1 (SD=3.0) for the
remainder of studies. There was no significant difference between the groups
(F[3,60]=0.25; p=0.864).
Figure 12: Incidents per violent patient by country
0 2 4 6 8 10 12 14
AUS
AUS
AUS
AUS
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CAN
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Figure 13: Incidents per violent patient by setting
0 5 10 15 20 25
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The proportion of violent patients who were responsible for more than one incident
was calculated for 31 studies. This figure ranged from 12% to 81% with a mean of
44.7 (SD=16.5). Again, the mean repeat rate was highest in forensic studies (54.0%,
SD=17.1) than studies from acute (44.9%, SD=17.9) or psychiatric hospital settings
(36.6%, SD=12.6). This did not quite achieve statistical significance (F[2,28]=2.82,
p=0.078). The available studies were distributed across too many countries to allow
analysis by country of origin.
3.8 Physical violence

Although a comparative analysis by type of violence could not be conducted, it was
possible to focus on physical violence because studies counting multiple categories of
violence would be the least likely to undercount these incidents.
Excluding studies which only measured physical violence, the proportion of incidents
involving physical violence ranged from 6% to 93%, with a mean of 45.0%
(SD=22.8). This was calculated for a sub-sample of 39 studies. It might be expected
that this proportion would be lower for studies which included more categories of
violence. The proportion of incidents involving physical violence for studies which
measured two categories of violence was 52.6% (SD=22.7) and 54% (SD=21.8) for
those which measured three categories. However, the proportion for studies reporting
four categories of violence was significantly lower (32.1%, SD=16.6; F[2,34]=5.49,
p=0.009). Comparison by definition also showed that studies which included verbal
aggression, physical violence, aggression to objects and self-harm had the lowest rate
(32.1%, SD=16.7; F[2,35]=4.76, p=0.015.
Studies of physical violence only were combined with those for which it was possible
to calculate a separate event or patient based rate for physical violence (n=50).
Patient based rates for physical violence ranged from 4% to 55% with a mean of
22.5% (SD=13.0). Event based rates ranged from 1.4 to 2069.1 with a mean of 219.5
(SD=447.6). Without the 2069 outlier [Rasmussen and Levander 1996], the mean
event based rate was 148.4 (SD=257.3).
Comparison of patient based rate by setting revealed no significant difference

(F[2,32]=1.04, p=0.366). The rate was 20.8% (SD=9.2) for acute wards, 27.9%
(SD=18.3) for forensic wards and 19.1% (SD=12.7) for psychiatric hospitals. After
dropping the outlier study, mean event based rates by setting were: 42.7 (SD=48.0)
for acute wards, 39.7 (SD=25.3) for forensic wards and 99.9 (SD=156.1) for
psychiatric hospitals. However, the differences were not statistically significant
(F[2,19]=0.73, p=0.495).
3.9 Staff surveys of violence

A separate analysis was conducted for studies which asked nurses and other clinical
staff about their experiences of violence. This excluded service wide recording
systems for violent incidents. To allow meaningful comparisons, only studies
reporting the proportion of sampled staff experiencing violence were included. Where
possible, rates for nurses and other staff were analysed separately.
Forty-two studies fulfilled these criteria. Most single country studies were from the
USA (n=10; 24%) or the UK (n=10; 24%). Others were from: Australia (n=3; 7%),
Taiwan (n=3; 7%), Canada (n=2; 5%), Japan (n=2; 5%), Sweden (n=2; 5%), Turkey
(n=2; 5%), Belgium (n=1; 2%), Norway (n=1; 2%), Poland (n=1; 2%) and
Switzerland (n=1; 2%). Two studies compared rates between the UK and Sweden,
and one between the UK and USA. A further study compared the USA, UK, Canada
and South Africa.
The vast majority of studies were of multiple ward types or hospitals (n=32; 76%). A
further four (10%) were from a mix of psychiatric inpatient and community staff, and
only data for the former were included in the review if possible. Two studies were
from acute ward settings and one from a forensic hospital. The setting was
unspecified in three studies. Twenty studies (48%) were of physical violence only
and three (7%) of verbal aggression only. Fifteen studies (36%) were of both verbal
and physical aggression. The remainder included other types of violence or were
unspecified.
Half of the studies (n=20; 48%) surveyed psychiatric nurses, seven surveyed
psychiatrists (17%), while 14 (33%) were of a mix of staff types (wherever possible,
separate rates were calculated for nurses, psychiatrists and other clinicians). One
study was of student nurses. In almost all cases (n=39; 93%) staff were asked about
their own experiences, but in three studies the questions were about staff observations
of violence on wards. The surveys usually asked about violence experienced during a
staff members professional career (n=19; 44%) or events during the previous year
(n=13; 31%). The others had various other reporting periods (n=8; 19%) and some
were unspecified (n=6; 14%). Note that some studies included data for more than on
time frame.
Rates of violence by staff type and time period are shown in Figure 14. A greater
proportion of nurses consistently reported experiencing violence during their career
(79%), the previous year (62%) and where the timeframe was unclear (80%). Data
for psychiatrists were only available for career based rates, but these were
substantially lower (43%). It is more difficult to interpret rates reported for all ward
or hospital staff, but the finding that they were lower than for nurses probably reflects
the inclusion of psychiatrists.
Figure 14: Proportion of staff reporting violence by profession and time period
90
80
70
60
50
%
40
30
20
10
0
Ever Year Unspecified
Nurses Psychiatrists Mix
Some studies did not include an overall violence rate but presented survey results by
violence type. A study from Taiwan reported that 35% of staff reported being the
victim of physical violence during the previous year and 51% were verbally abused
[Chen et al. 2009]. Over the course of a career, 83% of staff in another study had
experienced verbal aggression and 51% physical violence [Hatch-Maillette et al.
2007]. For studies of nurses, rates tended to be higher for both types of aggression.
Average career based rates were 71% for verbal aggression and 66% for physical
violence. Over the previous year, mean rates were 84% and 77% respectively. Only
one study of (trainee) psychiatrists reported rates by type and found 26% had been
assaulted in the previous year and 54% threatened [Pieters et al. 2005]. Rates for the
duration of residency were 72% and 56% respectively.
Four studies reported international comparisons. UK nurses experienced higher rates

of violence during the previous year than nurses from Sweden (71% vs 59%), and a
non-significant difference remained for physical aggression only (43% vs
33%)[Nolan et al. 2001]. A second comparison of these countries [Lawoko et al.
2004] found the same, with UK nurses reporting higher rates of verbal or physical
violence during their career (94% vs 84%) and during the previous year (73% vs
65%). The same study found a difference for psychiatrists in the same direction.
Rates for UK psychiatrists were 94% over a career and 53% over a year, compared to
86% and 58% in Sweden. A comparison of US and UK psychiatrists also found rates
to be marginally higher among the UK sample (rates over career: 20% vs 24%)[Hatti
et al. 1982]. Finally, one study compared physical violence rates for nurses in the
USA, UK, Canada and South Africa, although the mix of hospital settings from each
country was very different [Poster 1996]. Rates of any assault were significantly
higher in Canada (94%) than the UK (78%), USA (76%) and SA (51%).
3.10 Evidence for and against the City model
The review of violence rates offered little information which was relevant to the City
model. The studies reported wide ranging levels of violence, even within countries
and settings. This variation is likely to reflect differences in nursing practice, at least
to some degree, but further exploration was beyond the scope of this review which did
not consider nursing interventions.
3.11 Points the City model has missed

The analyses clearly show that raw rates of violence are highest in forensic services.
This was found within and across countries. Different management strategies are
likely to be needed for forensic patients, particularly as many have a history of violent
behaviour and their stay in hospital is often much longer than the typical acute ward
patient. The City model strives to reduce levels of conflict and containment to a
minimum, but the extent of possible reductions may well differ by service typology.
What seems a high level of containment in an acute ward may be the norm in a
forensic setting.
A small minority of patients were found to be responsible for multiple episodes of

violence. This was a consistent finding, with no significant difference in the mean
level of repeated violence between settings or countries. This has implications for the
City model in the sense that targeted approaches to violence reduction may be more
appropriate or effective than blanket strategies across the whole ward or hospital.
This may mean changing the way in which violent behaviour is managed for these
individuals or increasing efforts to tackle the root causes or triggers for violence if
they are known.
The level of violence and aggression reported by the studies suggests a high degree of
tolerance among staff, not least because they are frequently the victims of patient
violence and aggression. This is supported by the apparent gap between official
incidents and actual levels of violence and aggression reported by many studies. This
could be interpreted as evidence of positive appreciation among staff, but in the case
of verbal abuse in particular a certain amount of putting up with aggression seems
inevitable. However, this leaves the question of what is level of abuse is acceptable?
At what point should nurses intervene and how?
3.12 Discussion
Summary
Of the 424 studies included in the violence review, at least one rate was calculable for
30% of them. Rates varied markedly by country, setting, and settings within
countries. The proportion of patients involved in violence tended to be higher in the
UK, Australia and Scandinavia. In terms of the number of incidents, at least two were
reported per patient overall, with studies from Norway, the USA and UK reporting the
highest rates. The UK also had relatively high levels of staff victims of violence.
Forensic patients had the highest proportion of violent patients and highest rate of
violent incidents, but there was no difference between studies of acute patients and
those from psychiatric hospitals. Within countries, rates also tended to be higher
among forensic studies.
All the studies included physical violence, but there was huge variation in the
measurement of other types of violence. This makes comparisons across studies
difficult. Statistical tests found a modest influence of definition on overall rates of
violence. Studies confined to physical violence had higher rates of events per 100
occupied days while those which included verbal aggression had higher patient based
rates. Whether studies relied upon official reports of incidents or used observational
methods was not associated with rates of violence, except for patient rates per 100
occupied days. Forensic studies had the lowest proportion of physical violence only
studies (see below), which may be one reason why overall rates were higher in this
setting.
The findings must be interpreted with care. The availability of data to calculate each
measure of violence varied such that each comparison reported above included a
different sub-set of studies. Only eleven studies included data for each of the six
measures of violence. The distribution of violent incidents among the patient
population was skewed, with a minority of patients usually responsible for a large
proportion of the violence. On average, 45% of violent patients were involved in
more than one incident with each violent patient responsible for four incidents. There
was no pattern to repeated violence by country, setting or definition of violence.
Lessons for future research

Given the scale of the literature review, surprisingly few studies included data which
could be used to calculate rates of violence. The results differed by the type of
measure employed, with higher rates for forensic studies compared to acute wards
disappearing when controlling for occupied bed days. It can be concluded that a
higher proportion of forensic patients were violent and committed more violent acts,
but acute wards admit many more patients, including violent ones. When viewed as a
measure of exposure to risk, controlling for patient bed days takes account of these
differences and suggests that the chances of a violent incident occurring in a forensic
hospital is lower than for other psychiatric services. Such differences in the balance
between the number of admissions and static patient population probably also explain
a similar phenomenon observed for comparisons by country: some of those with high
rates per 100 admissions (e.g. UK) had comparatively lower rates per 100 occupied
bed days.
An important complicating factor for the review was the variation in definitions of
violence. This sometimes reflected different emphases in the papers. For example,
six studies were specifically focussed on staff victims of patient assault. Comparisons
between the studies indicated that differences in definition did not greatly influence
overall rates of violence. However, within studies it was commonly reported that
official incident reports under-reported the true extent of violence. There were also
interactions between definition, methodology and setting. Cross tabulation of these
variables showed that over twice the proportion of studies measuring physical
violence only used official data rather than observational methods (69% vs 31%; 2[1]
=3.74, p=0.053). By setting, forensic studies were significantly more likely to use
official data sources than observational methods (72% vs 28%; 2[3] =9.44, p=0.024).
The balance between official data and observational methods was more even for
studies of acute wards (46% vs 54%) and psychiatric hospitals (54% vs 46%).
Studies from psychiatric hospitals more likely to include physical violence only
(41%) than forensic (8%) and acute ward (24%) studies (2[3] =11.53, p=0.009).
From these complexities, it can be concluded that prospective studies of violence are
preferable to retrospective analysis of official incident reports and this applies to
studies from forensic services in particular. Studies which recruit patients across
ward types in psychiatric hospitals currently under-represent verbal aggression,
aggression to objects and self-harm. There remains, therefore, more research to be
conducted in order for a more complete picture of violence among psychiatric
inpatients to emerge.
4. THE ANTECEDENTS OF VIOLENCE AND AGGRESSION

Seventy one studies provided live, prospective antecedent data. This data is derived
from what was recorded about the reason why violence/aggression occurred.
Therefore, it should in theory be an accurate account of why the incident occurred,
rather than a subjective opinion or belief about why the incident occurred. Fifty-three
of these papers reported antecedent proportion data that was able to be meta-analysed.
Data source
There were 11 different sources of antecedents data. The most predominant of these
were incident forms (n=35 studies used this method), followed by the
SOAS/SOAS-R (Staff Observation Aggression Scale) ([Nijman et al.
1999;Palmstierna and Wistedt 1987];(Nijman et al. 1999) instrument (n=16),
qualitative follow-up interviews (which were carried out either immediately after the
incident or soon after) (n=9), ASAP (Assaulted Staff Action Program) (Flannery,
1999) (n=4), video recording (n=3), study-specific questionnaires (n=3), medical
claim documents (n=2), official records (clinical, legal, and/or case records) (n=2),
participant observation (n=1), and case studies (n=1).
Countries
Antecedent data was collected from 13 different countries. These were: USA (n=22
studies), UK (n=19), Australia (n=7), Norway (n=6), Sweden (n=4), Canada (n=4),
Italy (n=3), Taiwan (n=2), and Denmark, Finland, Germany, Netherlands, and
Singapore (all n=1).
Study settings
Twenty-six studies collected antecedent data from inpatient acute settings. Twenty-
two studies collected data from a mixture of settings, 14 studies collected data from
forensic settings, 6 from Psychiatric Intensive Care Units (PICU), 2 from Rehab units,
and 1 study collected data within a veteran setting.
Perspective
Sixty-eight studies collected data based on represented the staffs perspective of the
antecedent (63 of which collected data solely from this perspective), 5 studies
included data from the patients perspective (1 of which collected data solely from
this perspective), and 3 exclusively from the perspective of the video camera.
4.2 Thematic analysis
A thematic analysis of the antecedent data produced 59 distinct lower-level themes

which formed 9 higher-level themes: patient-patient interaction, staff-patient
interaction, patient conflict behaviours, external / personal themes, structural
themes, patient behavioural cues, patient emotional / mood cues, patient
symptoms, and no clear cause (see Table 1 for a full breakdown of these themes).
Table 1: Thematic analysis of antecedent
PATIENT-PATIENT STAFF-PATIENT PATIENT EXTERNAL / STRUCTURAL PATIENT PATIENT

INTERACTION INTERACTION CONFLICT PERSONAL ISSUES BEHAVIOURAL EMOTIONAL /
BEHAVIOURS CUES MOOD CUES
Physical contact Limiting patients Absconding Money issues ENVIRONMENTAL Agitation Anger
(1) freedoms attempt Visit from family ISSUES Attention Sexual
Patient engaged in MEDICATION RELATED Substance member or Overcrowding seeking frustration
an activity (1) CONTAINMENT misuse friend Confined behaviour Irritability
Intrusion into Medication Verbal Receiving bad environment Increased Tobacco
personal administration aggression news Noisy ward motor activity withdrawal
psychological or Staff requesting patient Threatening Unresolved Patient found Boisterousness Anxiety
physical space to take medication behaviour family problem weapons Confusion
Reaction to sexual Disputes over Self- REGIME ISSUES
approach medication harming Inadequate
PATIENT SYMPTOMS
Miscommunication ANY OTHER staffing levels

NO CLEAR CAUSE
(1) CONTAINMENT Admitted /
Victim doing Restraint transferred /
something patient Seclusion discharged
wanted stopped De-escalation Excessive
Competition ECT sensory
Retaliation ANY OTHER STAFF- stimulation
Patient victim PATIENT INTERACTION Lack of
characteristics Unspecified patient stimulation
Teased / bugged provocation (2)
Unspecified patient Ordering patients
provocation (1) Intervening on fight or
Unspecified argument
patient-patient Caring for patient
conflict Searching patients
Unspecified Negative staff attitude
patient-patient Physical contact (2)
interaction Patient engaged in an
activity (2)
Miscommunication (2)
Staff too permissive
Unspecified staff-
patient interaction
Staff victim
characteristics
Staff error
Patient-patient interaction
Thirty-four studies (47.9%) reported this theme. This included 12 lower-level themes that
related to an interaction between two or more patients as the reported antecedent to a violent
incident (see table 2). One of the lower-level themes was physical contact which was
reported as an antecedent by one study [Mellesdal 2003]. They defined this antecedent as
actual physical contact between two patients, or when an intrusion into the patients physical
or psychological space occurs. Using the Report Form for Aggressive Episodes data
collection tool prospectively over a period of 3 years within a Norwegian inpatient
psychiatric acute ward, they found that physical contact was the antecedent of 73 out 981
incidents (7.4%).
Table 2: Patient-patient interactions as recorded antecedents of violent incidents

N %
studies studies
used used
Lower-level this this Key differences across study
antecedent theme Definition theme theme background factors
Physical contact Physical contact between patient and 1 1.40% -
victim
Intrusion into personal Another patient enters into the percieved 4 5.60% -
psychological or psychological and/or physical space of
physical space another patient
Competition Two or more patients engaged in some 1 1.40% -

type of competition between each other
Patient engaged in an Patient engaged in an activity 1 1.40% -
activity*
Reaction to sexual One patient approaches another patient in 1 1.40% -

approach a sexual manner
Victim doing something Victim of aggression/violence was 1 1.40% -

which patient wanted engaging in a behaviour that the assailant
stopped wanted stopped
Retaliation The assailant retaliated on another patient 2 2.80% -
Patient victim The assailant became violent/aggressive 1 1.40% -

characteristics due to a characteristic of another patient
Teased/bugged The assailant was being teased or bugged 4 5.60% -

by another patient
Miscommunication* A communication problem between patient 5 6.90% -

and victim
Unspecified patient Patient was provoked by another person. 13 18.30% 5/13 UK-based studies, 7/12 sourced
provocation* Specific type of provocation is not stated. from SOAS/R, 5/12 within inpatient
acute settings.
Unspecified patient- An unspecified type of conflict occurred 9 12.60% 6/9 sourced from incident forms
patient conflict between two or more patients
Unspecified patient- An unspecified type of interaction occurred 5 6.90% -
patient interaction between two or more patients
* These themes were also coded within patient-patient interaction
Four studies reported intrusion into personal psychological or physical space as an
antecedent to violence. This included a case study of an aggressive schizophrenic patient at a
public psychiatric hospital who committed violence after his personal space was invaded
[Longo and Bisconer 2003]. Additionally, one study which evaluated aggressive incidents in
the dining rooms at a American state forensic hospital, reported this theme in relation to
patients cutting in line for food [Hunter and Love 1996]. Another study also showed evidence
of this through the use a video camera system installed within a PICU [Crowner et al. 2005].
They stated that the assailants in this study may have been especially sensitive to others
moving too close. Further, another study by revealed via a video camera system installed
within a PICU that violence occurred after the assailant invaded the victims personal space
by standing or pacing direct in front of the victim [Crowner et al. 1991]. This same study also
reported competition between patients over an (unspecified) object as antecedent to
violence.
Another lower-level patient-patient interaction antecedent of violence was patient engaged

in an activity. This was reported in a study that aimed to increase the understanding of
female aggression within Canadian inpatient forensic psychiatry settings [Nicholls et al.
2009]. After retrospectively reviewing official archive data, they found that female patients
were more often engaging some sort of activity prior to acting out aggression than male
patients.
The antecedent reaction to sexual approach was also only reported by one study [Harris
and Varney 1986]. In this 10 year prospective study of assaults and assaulters on a US
maximum security psychiatric unit, they found that 0.3% of staff (n not stated) and 0.5% (n
not stated) of assaulters reported this as an antecedent of violence. A potentially overlapping
theme to this was victim doing something which patient wanted stopped which was
reported by a study that examined PICU patients explanations of assaults [Crowner et al.
1995]. This theme was cited by assailants as the antecedent of 14.9% of violence incidents
(n=20 from total n incidents = 134). This study also reported the antecedent retaliation
which accounted for 9% of incidents (n=12). Retaliation was also reported by two other
studies as an antecedent to 9.4% (n=79) assaults within a US-based forensic service
[Quanbeck et al. 2007], as well as within a five month prospective study of aggression in a
large UK NHS psychiatric hospital [Shepherd and Lavender 1999] who attributed it as
antecedent for 12% of 130 incidents. This study also reported that in 6.9% of incidents, the
assailant committed a violent act because of the (patient) victims characteristics.
Four studies cited teased / bugged as an antecedent to violence. This included a study
which reported that assailants cited this theme for 18.6% of violent incidents (n=25)
[Crowner et al. 1995], while another reported that 6.4% of staff and 0.5% of assailants
reported this being teased/bugged as an antecedent to violence [Harris and Varney 1986].
Another study revealed that 5.9% (n=50) of assaults were due to bothersome/annoying
behaviour, while 1.8% (n=15) of assaults were due to a fellow patient talking/laughing at
them [Quanbeck et al. 2007]. Furthermore, a four month study of violence in a UK
psychiatric hospital found that patients being bugged for cigarettes was an antecedent to
violence [Casseem 1984].
Five studies reported the antecedent miscommunication. This included a retrospective

review of incidents in a UK psychiatric hospital in which 2% of 355 incidents were
precipitated by communication difficulties [Tobin et al. 1991]. Another study
retrospectively examined 590 assaultive child/adolescent and adult patients (via ASAP) from
Massachusetts, and found that 1% of assaults (n=6, total n=615) were precipitated by a
miscommunication [Flannery, Jr. et al. 2001],. Another US-based study, after examining
video-camera footage of an inpatient psychiatric ward over 18 months, found that assailants
became aggressive when they misunderstood the actions of their victims [Nolan et al. 2003].
A three year prospective study of a Norwegian inpatient psychiatric acute ward revealed that
communication problems preceded 30% of 981 aggressive incidents and were reported to
result in assaults in 55.4% of incidents [Mellesdal 2003]. They also reported that
miscommunication was significantly more frequently involved within cases of female
aggression (although no statistics were provided). Finally, this antecedent was reported for
7.9% of incidents (total n=1000) over a 13 month period within 3 UK-based psychiatric
hospitals after reviewing hospital untoward incident forms [Powell et al. 1994].
The antecedent unspecified patient provocation was reported by thirteen studies. This
included a UK-based prospective study in which 6.9% out of 130 incidents were triggered by
some sort of provocation [Shepherd and Lavender 1999]. Another study found that 46% of 35
assaults were preceded by an unspecified form of patient provocation [Crowner et al. 1991]s,
while a later study revealed 17.5% of 1000 incidents were preceded by unspecified
provocation from other patients, relatives or visitors [Powell et al. 1994]. A prospective study
of violent incidents in a UK forensic hospital in which 15% of 1144 incidents were due to
some sort of provocation [Larkin et al. 1988]. A study of physical assaults in a psychiatric
unit of an American general hospital revealed that 75.6% of 37 incidents involved mild or
moderate verbal provocation [Edwards et al. 1988], while a study of aggressive behaviour on
UK acute psychiatric wards where 11.4% of 264 incidents were due to unspecified
provocation [Foster et al. 2007], and a study of aggression in a Northern Irish psychiatric
female-only observation ward where staff interviews immediately after an aggressive incident
revealed 7% of 208 incidents were explained by this theme [Cooper et al. 1983]. A 7-year
Italian study of persistently assaultive inpatient acute psychiatric patients attributed this
theme to 32.8% of 409 incidents [Grassi et al. 2006], while a prospective study of violence
rates in a Danish psychiatric hospital and found that patients were responsible for provocation
in only 8 (5.1% of total) violent acts [Benjaminsen et al. 1996]. Another study examined
aggression among psychiatric inpatients in Australian rehabilitation wards, finding that
19.7% of 806 incidents were due to an unspecified type of provocation between patients
[Cheung et al. 1996]. Furthermore, another study investigated aggressive behaviour on a
Dutch acute psychiatric admissions ward and revealed that 14.4% of 164 incidents were
attributed to this theme [Nijman et al. 1997]. A Swedish study revealed this theme in relation
to crowding and aggressive behaviour on a PICU [Palmstierna et al. 1991], while another
Swedish study examined assaults on staff by acute psychiatric inpatients showed that 10% of
137 incidents were attributed to this theme by [Omerov et al. 2002],.
Overlapping with this theme was the antecedent unspecified patient-patient conflict. Nine
studies reported this: a study of aggression and violence in three UK-based inpatient acute
psychiatric wards which revealed that 14% of 221 incidents were preceded by this theme
[Duxbury 2002]; a prospective study of a UK secure forensic ward in which 5.6% of 178
were triggered by this type of conflict [Mortimer 1995], and a study of precipitants of
violence in a psychiatric inpatient setting in which 17.1% of 82 incidents were preceded by
conflict with another patient [Sheridan et al. 1990]. Additionally, a retrospective review of
incident forms within an UK psychiatric hospital showed that 17% of 355 incidents were due
to inter-patient friction [Tobin et al. 1991], while a prospective study of patient assaults in a
Canadian psychiatric hospital revealed that 4.5% of 201 incidents were due to this theme
[Cooper and Medonca 1991]. Furthermore, a study of four Taiwanese inpatient acute
psychiatric wards that revealed that 51.1% of 595 incidents were due to patient-patient
conflict [Chou et al. 2001], while another study attributed 2.5% (n=21) of incidents to this
theme [Quanbeck et al. 2007]. Finally, a prospective study of aggression in a UK psychiatric
hospital and an American study of assaults in an inpatient acute psychiatric settings (using
incident forms and follow-up interviews of patients and staff) also attributed incidents to this
theme [Shepherd and Lavender 1999] [Conn and Lion 1983]
The final lower-level patient-patient interaction theme was unspecified patient-patient

interaction which is defined an unspecified type of interaction between patients preceding a
violence incident. This was referenced by five studies: a five year Italian study of the
characteristics of violent behaviour in acute psychiatric in-patients in which 31% of 323 was
attributed to this theme [Grassi et al. 2001]; a UK study of the management of psychiatric
inpatient violence which revealed that 24% of 1515 incidents were triggered by an
unspecified interaction with patients (or staff) [Gudjonsson et al. 2004]; an investigation of
aggression in Canadian forensic psychiatry inpatients which found that this antecedent was
found by 14.3% (n=9) of 65 female patients and 25.2% (n=116) of 461 male patients
[Nicholls et al. 2009]; a study which revealed from patient follow-up interviews that 11% of
208 incidents were due to this theme [Cooper et al. 1983], and another study which attributed
this theme to 20.1% (n=27) of 134 violent incidents [Crowner et al. 1995].
Finally, it is important to note that the antecedents physical contact, patient engaged in an
activity, miscommunication, and unspecified patient provocation were also coded under
the higher-level theme of staff-patient interaction. This is because it was not possible to
determine which kind of interaction (patient-patient or patient-staff) had taken place within
the studies that reported these themes.
Staff-patient interaction
As can be seen in tables 1 and 3, this higher-level theme constituted 18 lower-level themes
which were divided into four categories: 1. Limiting patients freedoms (1 theme), 2.
Medication-related containment method (3 themes), 3. Any other containment (5 themes),
and 4. Any other containment methods (10 themes).
1. Limiting patients freedoms
More than half of all papers (n=37) cited this theme as an antecedent to violence. This
included many references to requests by patients being denied. In most instances (n=24/37)
studies did not specify the type of requests that patients made which were denied
[Benjaminsen et al. 1996;Cheung et al. 1996;Cheung et al. 1997;Conn and Lion 1983;Cooper
and Medonca 1991;Duxbury 2002;Flannery, Jr. and Walker 2008;Flannery et al. 2006;Foster
et al. 2007;Grassi et al. 2006;Gudjonsson et al. 2004;Harris and Varney 1986;Langsrud et al.
2007;Lim et al. 1991;Mellesdal 2003;Murray and Snyder 1991;Nicholls et al. 2009;Omerov
et al. 2002;Omerov et al. 2004;Palmstierna et al. 1991;Powell et al. 1994;Quanbeck et al.
2007;Rasmussen and Levander 1996;Shepherd and Lavender 1999]. Seven studies referred to
setting limits/restrictions as an antecedent to violence: one found that 59% of 1090
incidents were due to limit setting [Mellesdal 2003]; a one year study of 40 incidents were
due to staff limits [Murray and Snyder 1991]s, another found that 19.2% of 1000 were due
to unspecified clinical and legal restrictions [Powell et al. 1994], while four other studies
reported limit setting as a precipitant to violence without reporting proportion-type data
[Shepherd and Lavender 1999], [Hunter and Love 1996], [Lim et al. 1991], [Lanza 1988] .
Table 3: Staff-patient interaction as recorded antecedents of violent incidents
N
studies %
used studies
Lower-level antecedent this used this Key differences across
theme Definition theme theme study background factors
Limiting patients freedoms Patients requests denied and restrictions on patient 37 52.10% 17/37 studies within inpatient
privileges acute settings; 12/37 used
SOAS/R tool, 15/37 reviewed
incident forms
Medication Staff administrating medication to patients 19 26.80% 10/19 studies within inpatient
administration acute settings; 6/18 used
Medication-related
SOAS/R tool, 9/19 used

containment
incident forms
Staff requesting Staff requesting that a patient takes his/her 8 11.30% 6/8 studies within inpatient
patient to take medication acute settings; 5/8 used
medication SOAS/R tool
Disputes over A medication dispute between patient and staff 3 4.20% 3/3 studies within inpatient
medication acute settings
Restraint Staff physically restraining a patient 15 21.10% 5/15 US-based studies, 3/15
Canada-based studies; 5/15
Any other containment method
studies within forensic

settings; 8/15 studies used
incident forms
Seclusion Patients put in a seclusion area 7 9.90% 2/7 US-based studies, 2/7
Canada-based studies, and
2/7 Australian-based studies;
6/7 studies used incident
forms
De-escalation Staff attempted verbal de-escalation with patient 2 2.80% -
ECT The use of electro-convulsive therapy 1 1.40% -
Ordering patients Staff ordering/requesting patients to do something 12 16.90% 5/12 US-based studies; 5
studies within mixed settings;
7 studies used incident forms
Intervening on fight Staff intervening on a fight or argument between two 3 4.20% -

or argument or more patients
Caring for patient Staff caring or assisting patients in their daily activities 13 18.30% 3/13 Italian-based studies; 8
Any other staff-patient interaction
studies within inpatient acute

settings; 7/13 studies used
SOAS/R
Searching patients Staff searching patients for items 2 2.80% -
Negative staff Staff working with a negative attitude 1 1.40% -

attitude
Staff too Staff being too permissive of patients behaviour 1 1.40% -
permissive
Staff error An error made a staff member 1 1.40% -
Staff victim A characteristic of the staff victim triggered the 1 1.40% -

characteristics assailant
Unspecified staff- An unspecified type of interaction between two or 10 14.10% 5/10 UK-based studies; 2/10
patient interaction more patients within rehab settings; 4/10
used SOAS/R
Unspecified patient Patient was provoked by another person. Specific 13 18.30% 5/13 UK-based studies, 7/12
provocation* type of provocation is not stated. sourced from SOAS/R, 5/12
within inpatient acute
settings.
Physical contact* Physical contact between patient and victim 1 1.40% -
Patient engaged in Patient engaged in an activity 1 1.40% -

an activity*
Miscommunication* A communication problem between patient and victim 5 6.90% -
* These themes were also coded within patient-patient interaction
Five studies cited the request as patients wanting to leave the ward, including a UK-based 6
month study of assaults within an inpatient psychiatric hospital [Convey 1986]s, a 12 month
study of violent incidents in a Swedish inpatient psychiatric ward (in which 6 out 41 violent
incidents were attributed to this request) [Omerov and Wistedt 1997], a study of assaults on
staff within a locked UK-based inpatient psychiatric ward (11 out of 41 incidents) [Aiken
1984]s, a study of aggressive behaviour on a Dutch acute psychiatric admissions ward
[Nijman et al. 1997], and a four month study of violence in a UK psychiatric hospital
[Casseem 1984]. Four studies stated that denying the patient discharge from the ward
triggered violence, including a study of precipitants of violence in a US psychiatric inpatient
setting (3 out of 82 incidents) [Sheridan et al. 1990], violence among psychiatric inpatients at
a UK-based a locked acute ward and an interim secure unit (2 out of 70 incidents and 7 out
of 65 incidents respectively) [Agarwal and Roberts 1996], and two studies of Taiwanese
inpatient acute psychiatric wards (37 out 595 incidents and 35 out of 529 incidents) [Chou et
al. 2001];[Chou et al. 2002]. Requests related to cigarette smoking was cited by five studies
as an antecedent to violence, including the two Chou studies (2001: 68 out of 595 incidents;
2002: 111 out of 529 incidents respectively), a prospective of UK secure forensic ward
[Mortimer 1995]s, a prospective study of aggression in a UK psychiatric hospital [Shepherd
and Lavender 1999], and a study of patient assault in a large US-based neuropsychiatric
facility [Lanza 1988]. Another patient request which was denied and led to violence was for
off the ward privileges which was cited by both Chou et al studies (2001: 11 out of 595
incidents; 2002: 70 out of 529 incidents).
Two studies cited restrictions on food as antecedent to violence: a prospective study of a UK

secure forensic ward [Mortimer 1995], and a study of aggressive incidents in dining rooms at
an American state forensic hospital in which denying patient extra portions of food was the
reported antecedent to incidents 17% of times (denominator not stated) [Hunter and Love
1996]. Another study also cited restrictions upon patients demands for money (Mortimer,
1995), while a study on the impact of verbal abuse on inpatient acute psychiatric staff in
Singapore found that being denied a phone call was the antecedent of aggressive incidents
on 10% of occasions (out of 42 incidents), while being denied discharge, leave or parole
precipitated 14.3% of incidents [Yusuf et al. 2006].
2. Medication-related containment
This category of antecedents was reported by a total of 29 (40.8%) studies as an antecedent to

violence. It constituted three lower-level themes: administration of medication, staff
requesting that the patient takes his/her medication, and disputes over medication. Nineteen
studies (26.4%) reported administration of medication as an antecedent to violence [Grassi
et al. 2006];[Manfredini et al. 2001];[Grainger and Whiteford 1993];[Omerov et al.
2004];[Grassi et al. 2001];[Walker et al. 1994];[Powell et al. 1994];[Gudjonsson et al.
2004];[Sheridan et al. 1990];[Murray and Snyder 1991];[Flannery et al. 2006];[Nicholls et al.
2009];[Duxbury 2002];[Cooper and Medonca 1991];[Lion et al. 1981];[Chou et al.
2002];[Chou et al. 2001];[Bowers et al. 2002] . This theme referred to any incident being
precipitated by staff administering medication to patients.
The lower-level antecedent theme staff requesting that the patient takes his/her
medication was cited by eight studies (11.3%), four of which provided proportions data of
this antecedent. These included a study of aggressive behaviour in UK acute psychiatric
wards in which this theme was attributed as antecedent to 12.5% of 264 incidents [Foster et
al. 2007], a study of abuse in an inpatient acute ward in Singapore where 19% of 42 incidents
[Yusuf et al. 2006], and a study of violence rates in a Danish psychiatric hospital where staff
requesting patients to take their medication was an antecedent in 10.2% of 110 violent acts
[Benjaminsen et al. 1996]. The lowest proportion of incidents attributed to this theme was
reported for 6.8% of 512 incidents in two Norwegian acute psychiatric inpatient wards over a
seven year period [Langsrud et al. 2007]. Four other studies which cited this theme as an
antecedent of violence but did report proportion data: a study of violence in a Swedish
inpatient psychiatric ward [Omerov and Wistedt 1997], a study of aggression among
psychiatric inpatients in Australian rehabilitation wards [Cheung et al. 1996], a study of
aggression in a Dutch acute psychiatric admissions ward [Nijman et al. 1997], and a study of
crowding and aggressive behaviour on a Swedish PICU [Palmstierna et al. 1991].
The other medication-related lower-level theme was medication disputes. This was cited
as an antecedent by three studies: a study of staff assaults within a locked UK-based inpatient
psychiatric ward (9.8% of 41 incidents) [Aiken 1984], a three year study within a Norwegian
inpatient psychiatric acute ward (5.2% of 981 incidents) [Mellesdal 2003], and a study of
prevalence and precipitants of aggression within four Australian psychiatric inpatient units
(3.1% of 394) [Barlow et al. 2000].
3. Any other containment method
This category of antecedents was reported by a total of 20 (28.2%) as an antecedent to

violence and constituted four lower-level antecedent themes: restraint, seclusion, de-
escalation, and electro-convulsive therapy (ECT).
Fifteen studies (21.1%) cited restraint as an antecedent to violence, including a study which
attributed this antecedent to 70% of 88 incidents involving violent patients within a
Norwegian inpatient acute psychiatric ward [Blomhoff et al. 1990]. Other considerably high
proportions of incidents attributed to this antecedent were found in a study of workplace
assaults on ethnic minority mental health care workers in a Los Angeles psychiatric unit
(40.5% of 111 incidents) [Sullivan and Yuan 1995], a study of staff injuries sustained at a
forensic mental Health Centre in Ontario (38% of 123 incidents) [Harris et al. 1986], and a 27
month study of assaults in a Canadian psychiatric hospital (35% of 201 incidents) [Cooper
and Medonca 1991]s. A 3 year study of an American maximum-security forensic hospital
showed that 23% of 157 violent incidents resulting in staff injury involved the patient being
restrained immediately before the assault occurred [Hillbrand et al. 1996], while a
retrospective study of patient precipitants of violence within 10 public sector mental health
care facilities revealed that 15% of 193 violent incidents over a year were precipitated by
restraint procedures [Flannery, Jr. et al. 2003]. A similar proportion of this antecedent was
reported in a study of four Taiwanese inpatient acute psychiatric wards over a 7 month period
(14.3% of 595 incidents) [Chou et al. 2001]s. Lower reported proportions were reported to
be 4.5% from 838 assaults, 3.2% from 529 incidents, and 2.7% from 1000 incidents
([Quanbeck et al. 2007];[Chou et al. 2002];[Powell et al. 1994]). Five other studies reported
restraint as an antecedent to violence but did not report data on the proportion of incidents
that it was attributable for: a retrospective study of patterns of aggression in an Australian
forensic psychiatric hospital [Daffern et al. 2003], a study of violent incidents patterns in a
general psychiatric hospital also reported restraint [Tam et al. 1996], a study on the
development of the 'attacks' scale (attempted and actual assault scale) [Bowers et al. 2002], a
review of staff assaults at an American state psychiatric hospital [Lion et al. 1981], and a
study of violent incidents at a Norwegian maximum security forensic hospital [Rasmussen
and Levander 1996].
Seclusion as an antecedent to violence was reported by seven studies (9.9%), two of which
reported proportions data on this lower-level theme: a study which investigated injuries to
psychiatric staff working in high security, rehabilitation, acute, and geriatric units in an
Australian psychiatric hospital (7.3% of 328 incidents) [Grainger and Whiteford 1993], and a
study of assaults in an American inpatient acute psychiatric setting (32 of 24 incidents) [Conn
and Lion 1983]. Five other studies cited seclusion as an antecedent but did not report useable
proportions data ([Daffern et al. 2003];[Nicholls et al. 2009];[Tam et al. 1996];[Lion et al.
1981];[Rasmussen and Levander 1996]).
Two studies reported that the use of de-escalation was an antecedent to violence: a study in
which reported that attempting to calm an already aggressive patient was an antecedent to
further violence in 22% of 1945 incidents [Rasmussen and Levander 1996], while a study of
violence in a UK psychiatric hospital reported that one of the types of causes of violence
included talking and reassuring an aggressive patient [Casseem 1984]. Finally, there was one
mention of ECT as an antecedent of violence [Grainger and Whiteford 1993].
4. Any other staff-patient interaction
Just over half of all papers (n=36) cited this theme as an antecedent to violence. The lower-
level antecedent themes that it constituted were ordering patients, intervening on fight or
argument, caring for patient, searching patients, negative staff attitude, staff too
permissive, unspecified staff-patient interaction, unspecified patient provocation,
physical contact, patient engaged in an activity, and miscommunication. The last four of
these themes have also been included in the patient-patient interaction higher-level theme as
it was not possible to determine which kind of interaction (patient-patient or patient-staff) had
taken place within the studies that reported these themes. Therefore, a description of these
themes and the studies that cited them can be seen under the patient-patient interaction
report section.
Twelve studies (16.9%) cited that ordering patients triggered violence, five of which
reported data on the proportion of incidents that this antecedent counted towards. The highest
proportion was reported to be by 14.3% from 42 incidents of verbal aggression that were
triggered by staff advising patients to attend to their personal hygiene [Yusuf et al.
2006].Another study revealed that 14.1% of 838 assaults on staff occurred after the assailant
was directed to perform an activity by a staff member [Quanbeck et al. 2007]. A similar
proportion of incidents precipitated by this theme was reported to be 13% from 1945
incidents and 13% from 355 assaults ([Tobin et al. 1991]);[Rasmussen and Levander 1996]).
Lower proportions included 5% of 40 assaults [Murray and Snyder 1991], a study which
revealed that 16.8% of staff and 4.8% of assaulters reported that being ordered to do
something triggered an incident [Harris and Varney 1986], and a UK-based study of
aggression in a UK psychiatric hospital which reported that insisting on an activity
precipitated violence in 4.3% of 130 incidents [Shepherd and Lavender 1999]. Other studies
also reported this lower-level theme as an antecedent of violence but did not report useable
proportions data ([Longo and Bisconer 2003], [Sheridan et al. 1990], [Cooper and Medonca
1991], [Cheung et al. 1996] and [Lim et al. 1991]).
Staff intervening on a fight or argument between two or more patients was an antecedent
reported to be attributed to 14.3% of 328 incidents, 21% of 24 incidents, and 18% out of 203
[Grainger and Whiteford 1993]; [Conn and Lion 1983]; [Lion et al. 1981].
Thirteen studies reported that caring for patient was an antecedent to violence, ten of which
reported the proportion of incidents that this antecedent was applied to. This included a study
which reported that providing minimal or hands-on care accounted triggered 36% of 111
incidents [Sullivan and Yuan 1995], a three month prospective survey study abusive incidents
which found that 22.2% of 18 incidents in an adult psychiatric unit were due to a service
being provided [Yassi et al. 1998], and a study that revealed that providing care (which they
define as feeding, dressing, and recreation) preceded 20.4% of 328 incidents at Australian
psychiatric hospital [Grainger and Whiteford 1993]. Similar proportions were reported to be
19% of 1945 incidents [Rasmussen and Levander 1996] as well as by a study which found
that during an 8 week period in an Australian rehabilitation unit, 19.1% of 477 incidents were
preceded by theme [Cheung et al. 1997]. Smaller proportions were reported to be 10.2% of
512 incidents [Langsrud et al. 2007], 8% of 137 incidents [Omerov et al. 2002], 7.4% of 409
incidents [Grassi et al. 2006]), 7.1% of 323 incidents [Grassi et al. 2001] and 4.2% of 264
incidents [Foster et al. 2007]. A study by on day-night variation in aggressive behaviour
within an Italian psychiatric inpatient unit over a five year period also reported this
theme[Manfredini et al. 2001], as did another study who reported that assaults also occurred
when staff tried to help patients [Lanza 1988],while another study reported that some
assaults occurred after patients were fed or toileted [Lion et al. 1981]. The predominant
definition of this theme was found by studies that used the SOAS tool who referred to staff
assisting patients activities of daily living ([Rasmussen and Levander 1996],[Cheung et al.
1997],[Langsrud et al. 2007],[Omerov et al. 2002],[Grassi et al. 2006],[Grassi et al.
2001],[Foster et al. 2007])
Two other studies [Yusuf et al. 2006];[Cooper and Medonca 1991] also revealed that staff
searching patients was an antecedent to violence, although less frequently compared to other
antecedents. Specifically, the former revealed that checking for smoking triggered 8% of 42
incidents, while the latter found that staff taking something from a patient after searching
them triggered 3.5% of 201 incidents. One study cited that negative staff attitude was an
antecedent for 10.3% of 615 incidents [Flannery et al. 2006], while another found that staff
being too permissive (including letting patients into the staff office) triggered 5.6% of 178
incidents in a UK secure forensic ward over 31 months [Mortimer 1995]. Astudy of
aggression in a UK psychiatric hospital reported that a staff error precipitated violence in
1.7% of 130 incidents, and also reported that in 5.2% of incidents, the assailant committed a
violent act because of the (staff) victims characteristics [Shepherd and Lavender 1999].
The final lower-level staff-patient interaction theme was unspecified staff-patient
interaction which is defined an unspecified type of interaction occurring between staff and
patients that precedes a violence incident. This was cited by ten studies, three of which
inferred that did not provide useable data regarding the proportion of incidents that this theme
accounted for ([Manfredini et al. 2001], [Gudjonsson et al. 2004],[Shepherd and Lavender
1999]). The largest proportions were reported by to be (34.3% of 806 incidents and 69.9% of
477 incidents ([Cheung et al. 1996] and [Cheung et al. 1997] respectively), followed by a
study which reported that 18% of 221 incidents were triggered by some sort of staff-patient
interaction [Duxbury 2002]. It was also reported that 6.7% of 135 violent incidents at a UK-
based interim secure unit were due to an unspecified staff-patient interaction [Agarwal
and Roberts 1996], while a later study reported that this theme in relation to 2.2% of 595
incidents [Chou et al. 2001]. Another study revealed that that 0.2% of staff and 12% of
assaulters reported staff-patient interaction as an antecedent to violence [Harris and Varney
1986], while a study of aggression in a Northern Irish psychiatric observation ward revealed
that according to patients, 4% of 208 incidents were triggered by this theme, while according
to staff, 6% of the 208 incidents were due to this theme [Cooper et al. 1983].
Patient-conflict behaviours
Ten studies (14.1%) reported this theme. This included 5 lower-level themes of patient
conflict behaviours that were reported antecedents to violence (see table 4). The lower-level
theme was most frequently reported was patient displaying threatening behaviour. This
conflict-behaviour was cited as an antecedent to violence by three studies with proportion
data: an American study of violence among psychiatric inpatients in which 47% of 82
incidents were preceded by hostile behaviour [Sheridan et al. 1990]; a study of battery
incidents in a US-based maximum security hospital in which 10% of 221 battery incidents
were due to some sort of threatening behaviour (including provocative action, throwing an
object at someone, destruction of property, threatening action, striking an inanimate
object, and bizarre conduct) [Dietz and Rada 1982]; and a study which found that
intimidation was an antecedent to 8.2% of 838 incidents within a US-based forensic service
[Quanbeck et al. 2007]. Two other studies reference this theme: one which examined the
predictors of violence within a Norwegian maximum security unit [Linaker and Busch-
Iversen 1995], and another which examined PICU violence through the use of a video camera
system in which violence occurred after the assaulter displayed threatening gestures to the
victim [Crowner et al. 1991].
Table 4: Patient conflict behaviours as recorded antecedents of violent
incidents
%
Lower- studies
level N studies used
antecedent used this this Key differences across study
theme Definition theme theme background factors
Threatening Patient displaying threatening behaviour 5 6.90% 4/5 US-based studies; 2/5
behaviour studies within forensic settings
Substance Alcohol and/or drugs misuse 4 5.60% 4/4 studies used incident forms
misuse
Absconding An unsuccessful absconding attempt 3 4.20% 3/3 studies used incident forms
attempt
Verbal A patient being verbally aggressive 3 4.20% 3/3 studies within forensic
aggression settings
Self- Patient engaged in self-harming 2 2.80% -

harming
Substance misuse was cited as an antecedent by four studies: a study of violent incidents
within three UK-based psychiatric hospitals in which this antecedent was attributed to 1.2%
of 1000 incidents [Powell et al. 1994]s, a study of aggression and violence in three UK-
based inpatient acute psychiatric wards which revealed that 14% of 221 incidents were
preceded by this theme [Duxbury 2002], a study of aggression in a UK psychiatric hospital
which found that 1.7% of 130 incidents were triggered by substance misuse [Shepherd and
Lavender 1999], and a study of prevalence and precipitants of aggression within four
Australian psychiatric inpatient units which revealed that alcohol and drug use was an
antecedent for 2.9% of 394 incidents of aggression [Barlow et al. 2000].
The conflict behaviours absconding attempt and verbal aggression were both cited as
antecedents by three studies. The former was found to account for 7% of 1515 incidents,
5.4% of 1000 incidents, and 0.5% of 221 incidents ([Gudjonsson et al. 2004], [Powell et al.
1994], and [Dietz and Rada 1982] respectively), while the theme verbal aggression was
reported to precede 8.2% of 221 incidents and 2.9% of 838 incidents [Quanbeck et al. 2007] -
who specifically referred to patients making cold threats and [Dietz and Rada 1982] - who
referred to provocative and threatening talk respectively). Another study also cited verbal
threats as an antecedent to violence [Linaker and Busch-Iversen 1995]. Finally, a patient
engaged in self-harming was shown to precipitate 7.4% of 1000 incidents over a 13 month
period within three UK-based psychiatric hospitals [Powell et al. 1994], while a study of
violence, also within a UK psychiatric hospital, revealed that 4% of 355 incidents were
precipitated by this behaviour [Tobin et al. 1991].
External / personal issues
This higher level theme was referred to as antecedents to violence by eight studies. It
constituted three lower level themes: money issues, visit from a family member or friend,
and unresolved family problem (see table 5). Three studies referred to some sort of money
issue precipitating a violent incident. This included a study of staff assaults within a locked
UK-based inpatient psychiatric ward (3 out of 41 incidents were over money and cigarettes)
[Aiken 1984], a study of three UK-based psychiatric hospitals (2.6% of 1000 incidents were
precipitated by a problem related to monetary benefits and allowances) [Powell et al. 1994],
and a study of violence in a US-based psychiatric inpatient setting (7.3% of 82 incidents were
preceded by to a lack of money problems) [Sheridan et al. 1990].This study also reported
that unresolved family problems preceded violence (3.7% of 82 incidents), as did a study of
aggression within four Australian psychiatric inpatient units (4.9% of 394 incidents) [Barlow
et al. 2000]. Receiving a visit from a family member or friend was cited as an antecedent to
violence by three studies: a UK-based study of violence in inpatient acute psychiatric settings
revealed that 1% of 221 incidents were due to a visitor upsetting the patient [Duxbury 2002],
another UK-based study of a forensic ward in which 2.2% of 178 were triggered by visiting
time altercations [Mortimer 1995], and within a retrospective review of aggressive incidents
within Canadian inpatient forensic psychiatry settings who found that females were
numerically less likely than males to be aggressive whilst involved in an event such as
receiving a visit from a family member [Nicholls et al. 2009].
Table 5: External/personal issues as recorded antecedents of violent

incidents
N %
studies studies
used used
Lower-level this this Key differences across study
antecedent theme Definition theme theme background factors
Money issues Any monetary issue including problems with 3 4.20% -
benefits/allowances, lack of money, and a
financial dispute
Visit from family Assailant was visited in the ward by a family 3 4.20% -
member or friend member or friend
Unresolved family An unresolved family problem/issue 2 2.80% -

problem
Structural issues
As can be seen in table 6, this higher-level theme was divided into two categories of 7 lower-
level themes: 1. environmental issues (3 themes) and 2. regime issues (4 themes). Such
structural issues were reported by 13 papers (18.1%) in total.
Table 6: Structural issues as recorded antecedents of violent

incidents
N %
studies studies
used used
Lower-level antecedent this this Key differences across study
Overcrowding An over-crowded ward environment 1 1.40% -
Environmental issues
Confined environment A confined ward environment 1 1.40% -
Patient found weapons Assailant got access to objects that 1 1.40% -

could be used as a weapon
Regime issues
Inadequate staffing The level of staffing on ward was 1 1.40% -

levels inadequate
Admitted/ transferred/ Assailant was in the process of being 4 5.60% 3/4 studies within mixed psychiatric
discharged admitted, transferred or discharged settings; 3/4 studies used incident forms
from ward
Excessive sensory Assailant was overly stimulated 4 5.60% 3/4 studies used incident forms
stimulation
Lack of stimulation Assailant was under stimulated 2 2.80% 2/2 studies UK-based;2/2 studies within
mixed psychiatric settings; 2/2 studies
used incident forms
1. Environmental issues
Three papers cited environmental issues as the antecedent of violence. This included the
problem of overcrowding within wards which was cited as an antecedent by 1% of staff and
2.6% of assaulters (n not stated) in a longitudinal, prospective study of assaults in a US
maximum security psychiatric unit [Harris and Varney 1986]. A study of prevalence and
precipitants of aggression within four Australian psychiatric inpatient units found that 6.2%
of 394 incidents of aggression were precipitated due a patient being in a confined
environment [Barlow et al. 2000]. The other lower-level antecedent theme was patient
found weapons which was also cited by only one study who found that 2.8% of 178
incidents of violence in a UK secure forensic ward over 31 months were precipitated by this
occurrence [Mortimer 1995].
2. Regime issues
The latter study also revealed that inadequate staffing level was an antecedent in 14.6% of
178 incidents. A theme more frequently referenced as an antecedent was excessive sensory
stimulation. This was cited by a retrospective study of patient precipitants of violence in
which during one year, 14.2% of 193 violent incidents within 10 public sector mental health
care facilities were due to excessive sensory stimulation, [Flannery, Jr. et al. 2003] while a
later study revealed a similar proportion of incidents were precipitated by this antecedent:
14.6% of 615 incidents over a 3 year period within a public mental health care system in
Massachusetts [Flannery et al. 2006]. A retrospective 15 year analysis of the Assaulted Staff
Action Program used within the latter public mental health care system also cited this
antecedent as a key precipitant to violence in child and adult assaultive patients [Flannery, Jr.
and Walker 2008], while a 12 month study of violent incidents in a Swedish inpatient
psychiatric ward also cited this theme (specifically that some violent acts were activated by
response to stimuli) [Omerov and Wistedt 1997]. Linked to this theme was the antecedent
lack of stimulation, which a prospective study of aggression in a UK psychiatric hospital
reported as an antecedent of 3.4% of 130 violent incidents [Shepherd and Lavender 1999].
The most frequently cited regime issue as antecedent to violence was being admitted,
transferred, or discharged. Studies which cited this theme included a retrospective analysis
of recorded reasons for 1000 incidents within 3 UK-based psychiatric hospitals over 13
months in which this theme accounted for 2% of incidents [Powell et al. 1994]; a study of
violence precipitants in a psychiatric inpatient setting in which the transfer of a patient
accounted for 3.7% of 82 incident [Sheridan et al. 1990]; a study of staff assaults in a
veterans psychiatric hospital in which recent admission was cited as a trigger for 2.5% out
of 40 incidents [Murray and Snyder 1991]; an Australian study of aggression prevalence and
precipitants found that patient admission status accounted for 9.6% of 394 incidents
[Barlow et al. 2000]; while another study also reported this theme as an antecedent for 3.4%
of 130 incidents [Shepherd and Lavender 1999].
Patient behavioural cues
Nineteen studies (26.8%) reported this higher-level theme which included 5 lower-level
themes of behavioural cues as reported antecedents to violence (see table 7). The lower-level
theme by far the most frequently reported was patient agitation which was referenced by
11 studies, three of which also provided useable proportion data on this theme: a study of
staff injuries in a maximum-security forensic hospital (this antecedent was cited for 22% of
157 incidents [Hillbrand et al. 1996], a study of psychiatric inpatient violence (32% of 1515
incidents) [Gudjonsson et al. 2004], and a retrospective study of violent incidents on two
PICUs over a course of one year (in which 55.4% of 116 incidents the patient had been
showing signs of unsettled behaviour) [Coldwell and Naismith 1989]. Another study
reported that this antecedent, in tandem with disturbed behaviour, accounted for 31% of 1000
incidents over a 13 month period within 3 UK-based psychiatric hospitals [Powell et al.
1994]. Other studies that cited this theme as an antecedent and which also did not report
useable proportion data included a three month study of abusive incidents in an adult
psychiatric unit which reported that health care workers involved in an abusive event were
not completely surprised by the event as they believed that the assailants were often agitated
before incident occurred [Yassi et al. 1998]s. Another was a 10 year prospective study of
assaults and assaulters in a US maximum security psychiatric unit reported that 1.2% staff
and 5.3% assaulters reported building tension as antecedent of violence [Harris and Varney
1986]. A seven month prospective study on violent and aggressive incidents in Australian
psychiatric units found
Table 7: Patient behavioural cues as recorded antecedents of violent incidents
N studies % studies
Lower-level antecedent used this used this Key differences across study
Agitation Patient showed signs of agitation or 11 15.50% 5/11 studies UK-based, 4/11 US-based,
unsettled behaviour 2/11 Australia-based
Confusion Patient appeared confused 4 5.60% 2/4 Norway-based studies, 1/4 study
used video camera footage
Increased motor activity The patient increased their motor 3 4.20% 3/3 studies used incident forms
activity e.g. increasing their pacing
level
Boisterousness Patient appeared animated, noisy, 2 2.40% 2/2 Norway-based studies,

energetic, rowdy
Attention-seeking behaviour Patient behaviour that seeks the 1 1.40% --

attention of others
that of the 752 incidents rated as serious (from a total of 1,289 incidents), 82% were
preceded by a warning sign, commonly agitation [Owen et al. 1998], while in a different
paper by the same authors (and based on the same data), agitation as a warning sign for
recidivist aggressive patients [Owen et al. 1998]. Another study of precipitants of violence in
a psychiatric inpatient setting reported that 75% of 73 aggressive patients showed signs of
anxiety before the incident occurred [Sheridan et al. 1990], while a study of inpatient
violence found that within a locked acute ward over a course of year, 58% of 70 incidents
were precipitated by patients appearing as agitated, irritable while a year later within an
interim secure unit, 65% of 65 incidents were precipitated by these cues [Agarwal and
Roberts 1996]. Finally, a study on the development of the 'attacks' scale (attempted and actual
assault scale) stated that one of the most common antecedents [to violent incidents] were
agitated/disturbed behaviour (p. 108) [Bowers et al. 2002].
The next most frequently cited behavioural cue was patient confused which one study
reported to precipitate 40% of 40 incidents at a US-based veterans medical centre over the
course of a year [Murray and Snyder 1991]. Another study of violence predictors within a
Norwegian maximum security unit found that reported the presence patient confusion before
violent event [Linaker and Busch-Iversen 1995]. In another study, after examining video-
camera footage of an inpatient psychiatric ward over 18 months, assailants became
aggressive after misunderstanding the actions of their victims and appearing confused [Nolan
et al. 2003]. It has also been reported that that for patients in one of three Norwegian inpatient
acute wards who had been involved in violent incidents, a high incidence of confusion was
presented prior to the violent event [Almvik and Woods 1998]. This study and another
[Linaker and Busch-Iversen 1995] also cited boisterousness as a behavioural cue to violent
incidents.
The antecedent increased motor activity was cited by three studies: one in which violence
reports between 1992 and 1996 were retrospectively analysed in a Finnish forensic
psychiatric hospital and restlessness was attributed as antecedent in 55.5% of 616 incidents
[WeizmannHenelius and Suutala 2000], another in which 49% of 82 incidents were
precipitated by assailants pacing [Sheridan et al. 1990], and within a study of patterns of
violence in a general psychiatric hospital who also reported pacing [Tam et al. 1996].
Attention-seeking behaviour was another behavioural cue that preceded violence. This
was reported by a study of aggression in a Northern Irish psychiatric female-only observation
ward in which 24% of 208 incidents were attributed to this theme by staff [Cooper et al.
1983].
Patient emotional/mood cues
A total of 8 studies cited emotional or mood cues that were antecedents to violence (see table
8). One of the five lower-level themes that constituted this higher-level theme was anger.
This emotional cue was cited by three papers: a prospective study of violent incidents on a
US maximum security psychiatric unit in which 5.5 of staff (n not stated) and 2.2% of
assaulters (n not stated) stated that the assailant was angry at the ward
rules as an antecedent of violence [Harris and Varney 1986]; a study of patients
explanations of assaults within one US-based PICU in which anger was cited by assailants as
an antecedent of 11.9% of 134 violence incidents [Crowner et al. 1995]; and a study in which
unprovoked rage was as an antecedent to 1.9% of 838 assaults within a US-based forensic
service [Quanbeck et al. 2007].
Table 8: Patient emotional/mood cues as the recorded antecedents of violent

incidents
N %
studies studies
used used
Lower-level antecedent this this Key differences across study
Anger The patient felt angry 3 4.20% 3/3 US-based studies; 2/3 studies
from patients perspective
Irritability The patient felt irritable 3 4.20% 2/3 Norway-based studies; 2/3
studies based in forensic settings
Sexual frustration The patient felt sexually frustrated 1 1.40% -
Cigarette withdrawal The patient was experiencing withdrawal 1 1.40% -

symptoms from lack of cigarettes
Anxiety The patient felt anxious 1 1.40% -
The similar theme of patient irritability was also cited by three studies as an antecedent of
violence. Two Norwegian studies of violence reported the presence patient irritability before
a violent event, both within forensic and inpatient acute psychiatric settings respectively
([Linaker and Busch-Iversen 1995]; [Almvik and Woods 1998]). Finally, as previously
stated, a study of inpatient violence found that within a locked acute ward over a course of
year, 58% of 70 incidents were precipitated by patients appearing as agitated, irritable while
a year later within an interim secure unit, 65% of 65 incidents were precipitated by these
cues [Agarwal and Roberts 1996].
A UK-based study reported that patient sexual frustration was an antecedent to violence
for 7.9% of incidents (total n=1000) within psychiatric hospitals [Powell et al. 1994], while
cigarette withdrawal was inferred to in a study which cited a lack of cigarettes as an
antecedent of 4.3% of 130 violent incidents in a UK psychiatric hospital [Shepherd and
Lavender 1999]. Finally, a US-based study of violence precipitants reported that 75% of 73
patients had been anxious before they committed a violent act [Sheridan et al. 1990].
Patient symptoms
Twenty studies (28.1%) cited patient symptoms as an antecedent to violence, 16 of which

included usable proportions data (see table 9).
Table 9: Patient symptoms and no clear cause as the recorded antecedents of violent incidents
N %
studies studies
Lower-level used used
antecedent this this
theme Definition theme theme Key differences across study background factors
Patient Patient symptomology 20 28.10% 11/20 UK-based studies; 8/20 US-based studies,
symptoms 10/20 studies based in mixed settings, 6/20 studies
based in forensic settings, 16/20 studies used incident
forms
No clear No clear cause/precipitant 39 54.90% 13/39 US-based studies; 11/39 UK-based studies,
cause was identified by staff 3/39 Sweden-based studies, 3/39 Australia-based
studies, 15/39 studies based in inpatient acute
settings, 11/39 studies based in mixed settings, 4/39
studies based in PICU settings, 19/39 studies used
incident forms, 10 studies used SOAS/R.
The largest proportion of violent incidents that involved patient symptoms as an antecedent
was found in a study of aggression within four Australian psychiatric inpatient units where
65.7% of 394 incidents were attributed to the assailants mental state [Barlow et al. 2000]. A
similar proportion was ascribed by a study of aggression in a Northern Irish psychiatric
female-only observation ward where, according to staff, 62.3% of 208 incidents were
explained by this theme (specifically stating that patients were acting out hallucinations or
delusions) [Cooper et al. 1983]. However, the study also reported that according to patients,
8.2% of the incidents were precipitated by their symptoms. A study of aggression in a UK
psychiatric hospital also attributed a relatively large proportion of incidents to this theme -
38% of 130 incidents [Shepherd and Lavender 1999], while a similar proportion was ascribed
by a study in which 37.8% of 82 incidents were triggered by assailants delusional, paranoid
or hallucinated states [Sheridan et al. 1990]. A thirty-one month prospective study of a UK-
based forensic ward revealed that 32.6% of 178 were triggered by assailants disturbed
mental states [Mortimer 1995], while another study accredited a smaller proportion within
both a locked acute ward setting (21% of 70 incidents were precipitated by patients
psychotic state) and an interim secure unit setting (17% of 65 incidents) [Agarwal and
Roberts 1996]. A similar proportion (20% of 363 incidents) was revealed in a retrospective
study of incidents within a UK-based psychiatric hospital [Lim et al. 1991], as well as within
a study of assaults within a locked UK-based inpatient psychiatric ward in which 19.5% of 41
incidents were precipitated by paranoid and delusional beliefs [Aiken 1984]. This proportion
was closely matched with a finding of 19% of 355 incidents being precipitated by patient
psychosis in a retrospective study of incidents in a UK psychiatric hospital [Tobin et al.
1991], while another retrospective study of violence within 10 public sector mental health
care facilities revealed that 18.7% of 193 violent incidents over a year were precipitated by an
acute psychotic episode [Flannery, Jr. et al. 2003]. This antecedent was found to be slightly
raised in another Flannery et al study three years later when 16.4% of 615 incidents were
attributed to acute psychosis within a US-based public mental health care system [Flannery et
al. 2006]. A study of a maximum-security forensic hospital in America found that in 17.2%
of 157 incidents florid psychotic behaviour was noted in pts before assault occurred
[Hillbrand et al. 1996]s, while another study of chronically assaultive patients attributed
14.3% of 838 incidents to patient symptoms [Quanbeck et al. 2007]. One study of violence
within a UK-based inpatient acute psychiatric setting revealed that 13% of 221 incidents were
preceded by this theme [Duxbury 2002]. This theme was also reported by a prospective study
of assaults in a US-based forensic unit in which voices and delusional thoughts were
attributed as antecedents by 2.6% of staff and 3.1% of assaulters (n not stated) [Harris and
Varney 1986]. Another study also reported this theme when they reported that 286 incidents
(out of 1000) were preceded by patients in an agitated, disturbed state within 3 UK-based
psychiatric hospitals [Powell et al. 1994]. A study which retrospectively analysed data
extracted from clinical and legal records over 51 month period in which patients with
command hallucinations (a hallucination in which a person perceives spoken orders or
commands from an 'entity' within) were compared with those without such hallucinations for
assaultive behaviour within a forensic medium secure unit [Rogers et al. 2002]. They found
that out of 62 violent incidents, 18 command-hallucinators precipitated 74% of incidents
while 10 non-command hallucinators precipitated for 26% of incidents. Further, a
retrospective 15 year analysis of assaulted staff working within a public mental health care
service within Massachusetts found that patients symptoms of psychosis precipitated 33% of
sexual aggression incidents [Flannery, Jr. and Walker 2008]. Finally, a US-based and a UK-
based study of inpatient violence cited patient symptoms as important antecedents of violence
but did not report useable proportions data [Nolan et al. 2003] and [Casseem 1984]
respectively.
No clear cause
Thirty nine studies (54.9%) reported that there was no clear cause to a violent incident (see
table 9). Four of these studies did not report useable proportions data: a UK-based study of
inpatient acute violence who reported from their semi-structured questionnaire that most staff
did not recognise the antecedent of violence [Convey 1986], a case study of an aggressive
schizophrenic patient in at a public psychiatric hospital in which some staff perceived no
apparent cause or warning signs [Longo and Bisconer 2003], a study which revealed that
58.6% of staff and 15.4% of assailants reported that no reason or unknown when enquired
to the antecedent of incidents [Harris and Varney 1986], and a study of violent assaults in a
large US-based neuropsychiatric facility who reported that most assaults came without
warning [Lanza 1988].
The largest proportion of incidents attributed to this theme was reported in a UK-based
prospective study of violence in a forensic hospital in which 85% of 1144 incidents arose
spontaneously [Larkin et al. 1988].A US-based study of battery incidents in a maximum
security hospital found that 77.3% of 221 incidents were attributed to this theme [Dietz and
Rada 1982]; while a study of aggression in a Northern Irish psychiatric female-only
observation ward revealed a similar proportion - 75% of 208 incidents [Cooper et al. 1983],
and a three month study of abusive incidents in an adult psychiatric unit in which 66.7% of
18 incidents had no reported cause [Yassi et al. 1998]. A preliminary evaluation of the first
90 days of the Assaulted Staff Action Program in which 58.2% of 67 assaults were
unprovoked [Flannery et al. 1991]; while a study of video camera recordings installed within
a PICU revealed that 54.3% of 35 incidents did appeared that violence occurred after the
assaulter invaded the victims personal space by standing or pacing direct in front of the
victim were not preceded by a cue or warning [Crowner et al. 1991]. Lower proportions were
reported in a retrospective study of violent incidents on two PICUs over a course of one year
(in which 46.6% of 116 incidents patients were settled in the period immediately preceding
the incident) [Coldwell and Naismith 1989],a five year Italian study of the characteristics of
violent behaviour in acute psychiatric in-patients in which no cause was apparent for 44.6%
of 323 incidents [Grassi et al. 2001]; an investigation of aggressive behaviour on a Dutch
acute psychiatric admissions ward in which the provocation was not understood in 43.3% of
71 incidents [Nijman et al. 1997]s; and an examination of inpatient aggression in Australian
rehabilitation wards in which no apparent antecedents could be identified for 40.2% of 806
incidents [Cheung et al. 1996]. Similar proportions were cited in a 7-year study of
persistently assaultive inpatient acute psychiatric patients (39.9% of 409 incidents) [Grassi et
al. 2006], a Swedish study of aggressive behaviour on a PICU (38.7% of 119 incidents)
[Palmstierna et al. 1991], a study of violence at a Norwegian maximum security forensic
hospital (38% of 1945 incidents) [Rasmussen and Levander 1996], a study of violence within
a UK-based psychiatric hospital (36.9% of 363 incidents) [Lim et al. 1991], a study of violent
incidents in a UK psychiatric hospital (36.1% of 355 incidents) [Tobin et al. 1991], a
prospective study of violence in an Australian rehabilitation unit (35% of 477 incidents)
[Cheung et al. 1997], a study of aggression over the course of a year in a German psychiatric
hospital (34.7% of 441 incidents) [Ketelsen et al. 2007], and a retrospective study of violence
in a Finnish forensic psychiatric hospital (32.6% of 616 incidents) [WeizmannHenelius and
Suutala 2000]. Five studies reported proportions falling between 20% and 30%: a study staff
assaults among acute psychiatric inpatients (29.9% of 137 incidents) [Omerov et al. 2002], a
study of assaults within American inpatient acute psychiatric settings (29.2% of 24 incidents)
[Conn and Lion 1983], a UK-based study of aggression in acute psychiatric wards (26.5% of
264 incidents) [Foster et al. 2007], a UK-based study of aggression and violence in three
inpatient acute psychiatric wards (25.8% of 221 incidents) [Duxbury 2002], and a study of
assaults in a psychiatric unit within an American general hospital (24.3% of 37 incidents)
[Edwards et al. 1988]. Lower proportions were reported by in a review of staff assaults at an
American state psychiatric hospital (18.2% of 203 incidents) [Lion et al. 1981], a study of
staff injuries in two Norwegian acute psychiatric inpatient wards over a seven year period
(17.5% of 512 incidents) [Langsrud et al. 2007], a study of patient assaults in a Canadian
psychiatric hospital (14.9% of 201 incidents) [Cooper and Medonca 1991], and a US-based
study of precipitants to staff assaults over a 3 year period (12.2% of 615 incidents) [Flannery
et al. 2006]. The lowest proportions were revealed in a study of patients explanations of
assaults within one US-based PICU (9.7% of 134) [Crowner et al. 1995], a study on the
impact of verbal abuse on staff at Singapore-based inpatient acute psychiatric wards (9.5% of
42 incidents) [Yusuf et al. 2006], a study of assaults within a US-based forensic service
(8.6% of 838 incidents) [Quanbeck et al. 2007], a 12 month study of violent incidents in a
Swedish inpatient psychiatric ward (8.3% of 24 incidents) [Omerov and Wistedt 1997], a
study of events that preceded violent incidents within 3 UK-based psychiatric hospitals (7.9%
of 1000 incidents) [Powell et al. 1994], a study of staff assaults within a locked UK-based
inpatient psychiatric ward (7.3% of 41 incidents) [Aiken 1984], an investigation of staff
injuries working in high security, rehabilitation, acute, and geriatric units in an Australian
psychiatric hospital (6.1% of 328 incidents) [Grainger and Whiteford 1993]s and by study
of staff assaults in a veterans psychiatric hospital (2.5% out of 40 incidents) [Murray and
Snyder 1991].
4.3 Meta analysis

Fifty-three (74.6%) of the seventy-one papers with antecedent data also reported proportion
data which was used in a series of meta-analyses of the following 14 high- and medium-level
antecedent themes: patient-patient interaction, staff patient interaction (which included
limiting patient freedoms, medication-related containment, all other containment, and
any other staff-patient interaction), patient conflict behaviours, external / personal
issues, structural issues (which included environmental issues and regime issues),
patient behavioural cues, emotional / mood cues, patient symptoms, and no clear
cause. Only the medium-level theme environmental issues was not meta-analysed as only
two studies reported useable proportion data.
Table 10: Combined pooled estimate results of meta analyses of themes across all studies
Pooled Pooled
N of Pooled Rank of
High-level antecedent theme proportion proportion
studies proportion (%) proportion
<95% CI >95% CI
Patient-patient interaction 22 0.24 (24%) 0.17 0.3 5
Staff-patient interaction 41 0.39 (39%) 0.28 0.5 1
Patient conflict behaviours 8 0.1 (10%) 0.06 0.15 6
External / personal issues 7 0.03 (3%) 0.02 0.04 8
Structural issues 8 0.1 (10%) 0.05 0.16 6
Patient behavioural cues 7 0.38 (38%) 0.26 0.49 2
Emotional / mood cues 4 0.03 (3%) 0.01 0.05 8
Patient symptoms 15 0.28 (28%) 0.2 0.36 4
No clear cause 35 0.32 (32%) 0.24 0.41 3
A formal statistical test for heterogeneity using the I test (Higgins et al, 2003) was conducted
using Stata v11. The heterogeneity and robustness of pooled proportions were also explored
by conducting sensitivity analyses and a subgroup analysis of proportions based on incident
forms only, and proportions within acute inpatient psychiatric settings. The subgroup
analyses conducted were antecedent themes per psychiatric setting, per country, and per data
source. When heterogeneity was found to be statistically significant, a random effects model
was used.
The overall combined pooled estimate results of the themes can be found in table 10. It shows
that the antecedent theme which precipitates the highest proportion of violent and aggressive
incidents is staff-patient interaction, followed by patient behavioural cues, no clear
cause, patient symptoms, and limiting patient freedoms. The results of the subgroup
analyses can be found in tables 11 (incident forms subgroup analysis) and 12 (acute inpatient
psychiatric settings subgroup analysis) A full breakdown of the results of these themes across
all studies is now presented.
As can be seen in Figure 1, 21 studies were included in the meta-analysis of this theme
(Cooper et als 1983 study was entered twice as they provided antecedent data according to
the patient and staff perspective).
The overall pooled estimate was found to be 0.24 (95% CI= 0.17-0.30). The I was 99.1%
and significantly heterogeneous (p=.000). Sensitivity analyses were conducted to explore the
robustness of this observation. After removing those studies whose proportion and 95%
confidence interval were outliers (n = 2; Edwards et al, [1998] and Crowner et al [1995]), the
recalculated pooled proportion size was reduced to 0.20 (95% CI= 0.13-0.28). The I statistic
remained at 99.1% and remained significantly heterogeneous (p=.000).
A total of 41 studies reported proportion data pertaining to staff-patient interactions and were
included the meta-analysis. The pooled estimate was found to be 0.39 (95% CI=0.28-0.50)
(see figure 2). The I was 99.6% and significantly heterogeneous (p=.000). A sensitivity
analysis was not required as no studies produced proportion sizes or confidence intervals
considered to be outliers.
Four medium-level themes under the umbrella of staff-patient interaction were also meta-
analysed in order to examine which themes of interactions were producing the higher
antecedent proportions.
This included the theme limiting patient freedoms which produced an overall pooled
estimate of 0.25 (95% CI=0.18-0.31) across 27 studies (see figure 3). The I was 99% and
significantly heterogeneous (p=.000). The Langsrud et al (2007) study proportion was
considered an outlier and was removed for a sensitivity analysis. The I statistic decreased to
98.6% and remained significantly heterogeneous (p=.000), while the recalculated pooled
proportion was 0.23 (95% CI=0.17-0.29).
A meta-analysis of the theme medication-related containment produced a pooled proportion

size of 0.08 (95% CI = 0.06-0.09) across 21 studies (see figure 4). The I was 90.8% and
significantly heterogeneous (p=.000). The studies by Yusuf et al (2006) and Omerov et al
(2002) were dropped for a sensitivity analysis as their proportions and 95% confidence
intervals were considered outliers. This resulted in a recalculated pooled proportion size was
0.07 (95% CI = 0.06-0.09), while the I increased to 91.2% and remained significantly
heterogeneous (p=.000).
As can be seen in figure 5, the theme any other containment included a total of 13 studies
which were entered in a meta-analysis. The overall pooled estimate was found to be 0.22
(95% CI =0.16-0.27). The I was 98.4% and significantly heterogeneous (p=.000). For the
sensitivity analysis, one study was removed as its proportion size was considered an outlier
(Blomhoff et al, 1990). The pooled proportion size decreased to 0.18 (95% CI =0.13-0.23),
while the I statistic decreased to 98.2% and remained significantly heterogeneous (p=.000).
The final medium-level staff-patient interaction theme to be meta-analysed was any other
staff-patient interaction. This theme produced an overall pooled proportion size of 0.21
Figure 1: Meta analysis of 'Patient-Patient Interaction' all studies
(95% CI =0.14-0.28) (see figure 6). The I was 99.3% and significantly heterogeneous
(p=.000). The proportion sizes reported by Edwards et al (1988) and Cheung et al (1997)
were considered to be outliers and were removed for a sensitivity analysis. The I statistic
decreased to 97.8% and remained significantly heterogeneous (p=.000), while the
recalculated pooled proportion decreased to 0.16 (95% CI=0.12-0.20).
Patient conflict behaviours
Eight studies reported proportion data pertaining to patient conflict behaviours as antecedents
of incidents. A meta-analysis of these proportions revealed that the overall pooled estimate of
this theme was 0.1 (95% CI=0.06-0.15) (see figure 7). The I was 97.2% and significantly
heterogeneous (p=.000). One study was removed for a sensitivity analysis as its proportion
size was considered to be an outlier (Sheridan et al, 1990). This resulted in a recalculated
overall pooled estimate of 0.08 (95% CI=0.04-0.11), and a similar I value (96.8%) which
was significantly heterogeneous (p=.000)
A total of seven studies reported proportion data pertaining to external / personal issues and
were included the meta-analysis. The pooled estimate for this theme was 0.03 (95% CI=0.02-
0.04) (see figure 8). The I was 64.4% and significantly heterogeneous (p=.01). A sensitivity
analysis was not required as no studies produced proportion sizes or confidence intervals
considered to be outliers.
Figure 2: Meta analysis of 'Staff-Patient Interaction' all studies
Structural issues
As can be seen in figure 9, eight studies were included in the meta analysis of this theme, the
overall pooled estimate of which was found to be 0.1 (95% CI =0.05-0.16). The I was 95.9%
and significantly heterogeneous (p=.000). A sensitivity analysis was not required as no
studies produced proportion sizes or confidence intervals considered to be outliers. The
medium-level theme of regime issues was also meta-analysed (see figure 10). The overall
pooled estimate of this theme was found to be 0.09 (95% CI =0.04-0.14), while the I statistic
was found to be 94.8% which was significantly heterogeneous (p=.000). No studies reporting
regime issues proportion data were considered to be outliers in terms of proportion sizes or
95% confidence interval sizes and therefore a sensitivity analysis was not conducted.
Seven studies were included in the meta-analysis of patient behavioural cues precipitating
violent / aggressive incidents. The results showed a pooled estimate size of 0.38 (95% CI =
0.26-0.49) (see figure 11). The I was 97% and significantly heterogeneous (p=.000). No
Figure 3: Meta analysis of 'Limiting patient freedoms' all studies
Study %
ID ES (95% CI) Weight
Langsrud et al (2007) 0.65 (0.61, 0.69) 3.83

Grassi et al (2006) 0.14 (0.11, 0.18) 3.85
Yusuf et al (2006) 0.24 (0.11, 0.37) 3.40
Benjaminsen et al (1996) 0.51 (0.42, 0.60) 3.61
Omerov and Wistedt (1997) 0.25 (0.08, 0.42) 3.08
Yassi et al (1998) 0.06 (-0.05, 0.16) 3.54
Conn and Lion (1983) 0.13 (-0.01, 0.26) 3.37
Aiken (1984) 0.27 (0.13, 0.40) 3.35
Mellesdal (2003) 0.53 (0.50, 0.56) 3.85
Powell et al (1995) 0.19 (0.17, 0.22) 3.87
Mortimer (1995) 0.08 (0.04, 0.12) 3.83
Sheridan et al (1990) 0.28 (0.18, 0.38) 3.59
Shepherd and Lavender (1999) 0.07 (0.03, 0.11) 3.82
Murray and Snyder (1991) 0.10 (0.01, 0.19) 3.61
Foster et al (2007) 0.28 (0.23, 0.33) 3.79
Lim et al (1991) 0.19 (0.15, 0.23) 3.83
Agarwal and Roberts (1996) 0.07 (0.03, 0.12) 3.82
Flannery et al (2006) 0.18 (0.15, 0.21) 3.86
Duxbury (2002) 0.25 (0.19, 0.31) 3.78
Nijman et al (1997) 0.32 (0.25, 0.39) 3.72
Palmstierna et al (1991) 0.39 (0.31, 0.48) 3.64
Rasmussen and Levander (1996) 0.03 (0.02, 0.04) 3.89
Chou et al (2002) 0.41 (0.37, 0.45) 3.83
Quanbeck et al (2007) 0.09 (0.07, 0.11) 3.87
Chou et al (2001) 0.19 (0.16, 0.23) 3.85
Omerov et al (2002) 0.47 (0.38, 0.55) 3.66
Cheung et al (1997) 0.26 (0.22, 0.30) 3.83
Overall (I-squared = 99.0%, p = 0.000) 0.25 (0.18, 0.31) 100.00
NOTE: Weights are from random effects analysis
-.2 0 .2 .4 .6 .8 1
sensitivity analysis was undertaken as no studies were considered outliers in terms of

reported proportion sizes or confidence intervals.
Patient emotional / mood cues
As can be seen in figure 12, the theme included a total of four studies which were entered in a
meta-analysis. The overall pooled estimate was found to be 0.03 (95% CI =0.01-0.05). The I
was 76.5% and significantly heterogeneous (p=.000). A sensitivity analysis was not
conducted due to the small number of studies included in this analysis.
Patient symptoms
A total of 16 studies reported proportion data pertaining to patient symptoms as an antecedent

to violent and aggressive incidents. The pooled estimate for this theme was found to be 0.28
(95% CI=0.20-0.36 (see figure 13). The I was 97.7% and significantly heterogeneous
(p=.000). The proportion sizes reported by Barlow et al (2000) and Cooper et al (1988) were
considered to be outliers and were removed for a sensitivity analysis. Removing these studies
reduced the I statistic to 84.1% and remained significantly
Figure 4: Meta analysis of 'Medication-related containment' all studies
heterogeneous (p=.000), while the recalculated pooled proportion decreased to 0.22 (95%
CI=0.18-0.26).
No clear cause
The meta-analysis of this theme included a total of 35 studies which produced an overall
pooled estimate of 0.32 (95% CI =0.24-0.41). The I was 99.4% and significantly
heterogeneous (p=.000). After removing those studies whose proportion and 95% confidence
interval were outliers (n = 12; Grainger and Whiteford [1993], Omerov and Wistedt [1997],
Yassi et al [1998], Aiken [1984], Powell et al [1995], Larkin et al [1988], Dietz and Rada
[1982], Murray and Snyder [1991], Quanbeck et al [2007], Cooper et al [1983], Crowner et al
[1991], and Flannery et al [1991]), the recalculated pooled proportion size was 0.31 (95% CI
= 0.26-0.36). The I statistic decreased to 95.5% and remained significantly heterogeneous
(p=.000).
Figure 5: Meta analysis of 'Any other containment' all studies

Figure 6: Meta analysis of 'Any other staff-patient interaction' all studies
Figure 7: Meta analysis of 'Patient conflict behaviours' all studies
Figure 8: Meta analysis of 'External / personal issues' all studies

Figure 9: Meta analysis of 'Structural issues' all studies
Figure 10: Meta analysis of 'Regime issues' all studies

Figure 11: Meta analysis of 'Patient behavioural cues' all studies
Figure 12: Meta analysis of 'Emotional / mood cues' all studies

Figure 13: Meta analysis of 'Patient symptoms' all studies
Figure 14: Meta analysis of 'No clear cause' all studies
Table 11: Combined pooled estimate results of meta-analyses of themes across all studies using incident forms only and
SOAS/SOAS-Rs only (all other data sources excluded from meta analyses due to low numbers).
Rank of
Rank of
Pooled proportion
Pooled Pooled proportion
N of proportio (using
High-level antecedent theme Type of data proportion proportion (using
studies n <95% incident
source (%) >95% CI SOAS/SOAS-
CI forms
R only)
only)
SOAS/SOAS-R 9 0.26 (26%) 0.14 0.39 3
Incident forms 8 0.19 (19%) 0.1 0.29 5
SOAS/SOAS-R 12 0.52 (52%) 0.41 0.63 1

Incident forms 15 0.32 (32%) 0.11 0.53 3
SOAS/SOAS-R 0 n/a n/a n/a -

Incident forms 8 0.10 (10%) 0.06 0.15 6

Incident forms 6 0.03 (3%) 0.02 0.04 8

Structural issues
Incident forms 5 0.09 (9%) 0.02 0.15 7

Incident forms 5 0.40 (40%) 0.25 0.55 1

Emotional / mood cues
Incident forms 3 0.02 (2%) 0.02 0.03 9

Patient symptoms
Incident forms 10 0.28 (28%) 0.18 0.38 4
SOAS/SOAS-R 10 0.35 (35%) 0.29 0.41 2

No clear cause
Incident forms 13 0.33 (33%) 0.17 0.5 2
Table 12: Combined pooled estimate results of meta-analyses of themes across all studies based within inpatient acute, forensic and other
settings
Pooled Rank of Rank of Rank of

Type of data N of <95%
High-level antecedent theme proportion >95% CI proportion proportion proportion
source studies CI
(%) (inpatient) (forensic) (other)
Inpatient acute 10 0.27 (27%) 0.16 0.38 3 - -
Patient-patient interaction Forensic 2 n/a n/a n/a - - -
Other 10 0.22 (22%) 0.15 0.29 - - 5
Inpatient acute 20 0.49 (49%) 0.3 0.68 1 - -
Staff-patient interaction Forensic 6 0.23 (23%) 0.1 0.39 - 2 -
Other 14 0.34 (34%) 0.24 0.43 - - 2
Inpatient acute 3 0.03 (3%) 0.01 0.07 5 - -
Patient conflict behaviours Forensic 2 n/a n/a n/a - - -
Other 3 0.19 (19%) 0.06 0.33 - - 6
Inpatient acute 3 0.04 (4%) 0.01 0.08 9 - -
External / personal issues Forensic 2 n/a n/a n/a - - -
Other 2 n/a n/a n/a - - -
Inpatient acute 1 n/a n/a n/a - - -
Structural issues Forensic 1 n/a n/a n/a - - -
Other 6 0.09 (9%) 0.02 0.15 - - 7
Patient behavioural cues Forensic 2 n/a n/a n/a - - -
Other 4 0.40 (40%) 0.29 0.57 - - 1
Emotional / mood cues Forensic 1 n/a n/a n/a - - -
Other 3 0.05 (5%) 0.01 0.09 - - 8
Inpatient acute 3 0.33 (33%) -0.06 0.72 2 - -
Patient symptoms Forensic 4 0.23 (23%) 0.14 0.32 - 2
Other 8 0.27 (27%) 0.18 0.37 - - 4
Inpatient acute 13 0.26 (26%) 0.17 0.35 4 - -
No clear cause Forensic 5 0.48 (48%) 0.17 0.8 - 1 -
Other 17 0.32 (32%) 0.24 0.41 - - 3

Table 13: Combined pooled estimate results of meta-analyses of themes across all UK and US-based
studies (other countries excluded due to low numbers)
Pooled Rank of Rank of
N of <95% >95%
High-level antecedent theme Country proportion proportion proportion
studies CI CI
(%) (USA) (UK)
UK 7 0.19 (19%) 0.12 0.26 4

USA 4 0.28 (28%) 0.04 0.52 4
UK 9 0.33 (33%) 0.23 0.42 1

USA 10 0.31 (31%) 0.2 0.42 3
UK 4 0.06 (6%) 0.01 0.11 6

USA 3 0.24 (24%) 0.1 0.38 5
UK 4 0.02 (2%) 0.01 0.03 7

USA 2 n/a n/a n/a -
UK 3 0.08 (8%) 0.01 0.16 5

Structural issues
USA 4 0.1 (10%) 0.03 0.18 7
UK 2 n/a n/a n/a -

USA 3 0.32 (32%) 0.11 0.54 1
UK 2 n/a n/a n/a -

Emotional / mood cues
USA 2 n/a n/a n/a -
UK 7 0.23 (23%) 0.18 0.29 3

Patient symptoms
USA 6 0.20 (20%) 0.16 0.25 6
UK 9 0.33 (33%) 0.06 0.6 1

No clear cause
USA 10 0.32 (32%) 0.2 0.44 1
One of the underlying assumptions of the City model is the way staff can directly influence
the likelihood of conflict and containment levels, particularly through the way that they
interact with their patients. Therefore, the finding of staff-patient interaction precipitating an
estimated 40% of aggressive/violent incidents provides compelling evidence of this
assumption, as does the finding of 59 out of 71 papers (83%) reporting some sort of staff-
patient interaction as an antecedent to incidents.
One of the key moderators of conflict and containment levels in the City model is the role of
effective structure. This model component is supported by this review as limiting patients
freedoms was found to frequently precipitate violence/aggression (an estimated 25% of
incidents) and was reported by 37 papers in total (52%). The level and type of limits that are
placed upon patient behaviour and conduct can be influenced by the structure of the ward
which includes rules about restrictions on objects and behaviour. Further support of the
importance of an effective structure is highlighted by the finding that regime issues such as
inadequate staff-levels, boredom, and excessive sensory stimulation were reported by 10
papers as antecedents of violence/aggression (which were estimated to trigger 9% of
incidents).
The review also lends evidence to the importance of technical mastery in influencing the
outcome of conflict and containment levels. This is because the review revealed that
emotional/mood and, in particular, behavioural cues are presented by assailants prior to an
incident occurring. Staff who are skilled in recognising such cues should be able to pre-empt
and minimise the likelihood of an aggressive/violent incident from occurring. Further support
for the importance of technical mastery is highlighted by the fact that carrying out
containment methods, especially restraint, seclusion and de-escalation, can contribute to the
likelihood of violent/aggressive incident occurring (non-medication related containment is
estimated to precipitate 22% of incidents). If containment measures are carried out by
effectively by staff, the likelihood of such a conflict event occurred can be reduced.

The City model does not explicitly include the role of patient-patient interaction in the
production of conflict and containment outcomes. This theme was found to be an important
precipitant to violence/aggression as it was reported by 34 of the 71 papers (48%) and was
estimated to precipitate 24% of violent/aggressive incidents. The model also does not include
a consideration of how issues that are external and personal to the patient (such as receiving
bad news, family and money issues) may influence conflict and containment outcomes. The
effect of patient symptoms (estimated to precipitate 28% of incidents and reported by 21
papers as an antecedent) and the physical environmental (such as overcrowding, a confined
physical environment, noisiness) are also not included (although the latter was only reported
by 3 papers).
Although the effect of limiting patient freedoms on conflict and containment is influenced by
the models components of effective structure and technical mastery, this reviews findings
indicate that more explicit and direct consideration of this theme may be strengthen the
model. Finally, the City model does not emphasise the inter-relationship that exists between
conflict and containment. This relationship is emphasised by the finding of containment
measures (such as medication, restraint, seclusion, de-escalation) being reported as
antecedents of violence/aggression by a total of 29 papers, while non-related medication
containment was estimated to trigger 22% of incidents.
4.5 Discussion
One of the clearest findings depicted in this review is that antecedents of violent and/or
aggressive incidents are wide-ranging. This is underlined by the fact that there were in total
59 distinct lower-level antecedent themes across the 71 studies included in this review.
Antecedents ranged from specific types of interactions between patients and patients, patients
and staff, other conflict behaviours, issues relating to external source or of a personal nature,
structural issues within wards, patient symptoms, and behavioural and emotional cues.
However, it is important to consider that these themes and the extent to which they trigger
incidents are predominantly staff-based constructions of reality. It is the psychiatric staff
members who interpret their personal view of the incident and subsequently complete an
incident form, a SOAS/R, a study questionnaire, a claim form, an assault form, and/or who
are qualitatively interviewed. Sixty-three (89%) of the 71 studies reported antecedent data
exclusively from the staffs perspective of the incidents, while only five papers (7%) captured
the patients perspective. Such a large disparity of perspectives underlines the importance of
viewing this reviews findings as predominantly a representation of the staffs views of
antecedents, and that the true breadth and scope of antecedents of violence and aggression
remains uncertain.
A key reason for the existence of this disparity is that psychiatric wards are focusing on the
staffs recording of the antecedents of incidents. This is underscored by the finding that 8 out
of the 11 different sources of antecedent data revealed in this review were exclusively staff-
centred outcome measures such as incident forms and the SOAS/R. Participant observation
was used by only one study [Murray and Snyder 1991], while video camera footage of
incident was analysed by just three studies ([Crowner et al. 1991], [Crowner et al. 2005] and
[Nolan et al. 2003]). Qualitative follow-up interviews of patients following an incident were
carried out by five studies ([Aiken 1984], [Harris and Varney 1986], [Edwards et al. 1988],
[Crowner et al. 1995], and [Cooper et al. 1983]) compared to nine studies which interviewed
staff members. Studies that retrospectively analyse the antecedent data are only able to utilise
what data is available to them. However, prospective studies have the opportunity to analyse
the precipitating factors of an aggressive/violent incident from a patients perspective and
should be encouraged to do so. Where possible, prospective studies should also utilise video
camera footage, or retrospectively analyse existing video camera footage. Researchers may
also find it useful to cross-check their interpretation of video-camera footage with the
assailant, staff and/or witness as source of validation. This type of research is necessary in
reducing the perspective disparity and augmenting our understanding of what triggers
violence and aggression.
Another advantage of involving patients in research studies interested in antecedents to

violence/aggression is that they can elicit an understanding of how the patient felt prior to the
incident occurring. Enhancing our knowledge of such cues may help staff become better at
sensing or feeling a patients emotional state prior to an incident occurring, and lead to a
greater psychological understanding. The current state of literature illustrates that a far
greater level of reporting goes into understanding the behavioural cues prior to an incident
20 studies reported assailants behavioural cues prior to an incident, but only 8 studies
reported assailants emotional cues. This disparity is likely to be a consequence of it being
easier for staff to recognise a behavioural cue than an emotional cue prior to an incident, and
also because such few studies consider the patients perspective in their examination of
antecedents.
Despite a greater emphasis within the literature on reporting what happened prior to the
incident compared to how the assailant was feeling before an incident, many lower-level
antecedent themes were infrequently reported (for example, assailants reaction to sexual
approach, attention-seeking behaviour, physical contact between patients and/or staff,
assailants finding potential weapons, being in a confined or over-crowded environment,
competition between patients all n=1). It is debateable as to whether the implication of this
is that such antecedents are less important and less frequently triggers of aggression/violence,
or whether they being under-reported. If the latter is considered true, then the root of the
under-reporting may be the recording tools used by wards and research studies. For example,
if a violent incident was triggered because two patients were being overly-competitive with
each other while playing a computer game, this detail may be lost within a recording form
such as the SOAS-R which has a pre-defined category of provoked by other-patient.
Therefore, psychiatric staff should record the precipitating factors prior to a
violent/aggressive incident in as much detail as possible so that the richness of the data can be
preserved. This need is substantiated by the fact that 13 studies reported that the antecedent of
violence/aggression was patient provocation and that 15 studies reported that the antecedent
was some form of unspecified staff-patient or patient-patient interaction.
In keeping for the call of greater antecedent recording detail, one of the most salient findings
was that more than half of the literature (n=37 papers) cited that limiting patients freedoms
was a trigger of aggression/violence, yet the majority of these studies (n=24) did not specify
what the nature of the requests/freedoms being denied. This may again be due to a low level
of recording detail by ward staff, or a consequence of studies not providing further details
despite its availability. The need for a greater understanding of what requests and freedoms
are being denied is strongly emphasised by the meta-analysis finding of this theme being
estimated to be antecedent of 25% of violent/aggressive incidents a comparatively high
estimate compared to the 12 other themes meta-analysed.
Further support for the call of greater antecedent recording detail comes from the fact that 35
(49%) of the studies stated that in one of more incidents, no clear cause could be attributed an
incident. Perhaps even more concerning, the results of meta-analyses revealed that there was
no clear cause for an estimated 32% of incidents. This either implies that approximately 32%
of incidents are unprovoked (which is unlikely), that staff are failing to recognise existent
antecedent(s), or that staff are recognising the antecedent(s) but are not recording them. If
staff are unsure about the antecedent(s) of an incident, they should attempt to reflect further,
converse with any witnesses of the incident, and/or directly ask the assailant at an appropriate
time after the incident.
Another key point to be considered is that the sequence of antecedents could not be
established from the data. Therefore, the data does not necessarily represent the immediate
precursors to an incident, but instead what precipitating phenomena were perceived to be
present at an unknown time point prior to an aggressive/violent incident.
The meta-analyses of the antecedent themes estimated that staff-patient interactions are the
most frequent types of antecedents (39% of all incidents involved a staff-patient interaction
antecedent). An examination of the medium-level staff-patient interaction themes revealed
that limiting patients freedoms, either by placing some sort of restriction or denying a patient
request, was the most frequent precursor of incidents. The other staff-patient interaction
themes related to containment procedures and all other types of interactions such ordering
patients, searching patients, and intervening on an argument or fight. This finding
underscores the influence that staff have in making wards safe and efficacious environments.
It also highlights that most violent incidents are preceded by the staff exercising their power
over the patient. Therefore, prospective interventions aimed at reducing inpatient violence
and aggression should include methods centred on enhancing staff-patient interactions,
particularly in terms of finding better ways to manage patient requests and increasing staffs
technical mastery of containment procedures so that the risk of escalating an aggressive
incident is not increased. It may also be important to reduce the real or perceived level of
power differences that exist between staff and patients, either by giving patients more powers
and freedoms, or staff exercising their position of power less liberally and only when the
situation necessitates it.
The behavioural cues associated with the expression of aggression was the second most
frequently reported antecedent of violent incidents, with an estimated 38% of incidents
precipitated the assailant displaying signs of agitation, attention-seeking behaviour, increased
motor activity, boisterousness, and/or confusion. This is not an unexpected finding as it is
likely that assailants will be displaying such cues just prior to an incident occurring. Further,
as already stated, staff should find it easier to recognise such behavioural cues compared to
emotional/mood cues prior to an incident. An implication of this finding is that staff the
presentation of such cues should provide staff with an opportunity to be pre-empt an incident
from occurring.
The results of the meta-analyses also revealed that the approximately 1 in 4

aggressive/violent incidents are estimated to be triggered by a type of patient-patient
interaction. This finding implies that it may be beneficial if staff encourage and support
patients in positively interacting with other patients, such as helping them to appreciate each
other and communicate with each other in positive and constructive ways. If conflicts arise,
staff should find ways that de-escalate the conflict before an incident occurs, such as finding
a resolution, offering a compromise, or, if necessary, removing them from each others
vicinity.
It is also important to consider that the heterogeneity of the meta-analyses was very high and
therefore these results should be treated with caution This is demonstrated by the high I2
scores and the large confidence intervals, which were also present for each of the pooled
estimates. It was anticipated that splitting the meta-analyses by setting, country, and, in
particular, data source would significantly lower heterogeneity and tighten the confidence
intervals, however the variability between the studies remained high. Filtering the data in this
manner also did not produce any differences of note within the data. The fact that the pooled
proportion estimates were relatively similar when incident forms were compared to the
SOAS/R data collection tool implies that the high variability that exists is not due to the
reliability of the data collection methods, but rather due to important differences across the
studies (e.g. cultural differences, regime/practice differences etc).
5. THE CONSEQUENCES OF VIOLENCE AND AGGRESSION

One hundred and eight studies provided live, prospective consequences data. This data is
derived from what was recorded immediately after the violence/aggression occurred.
Therefore, it should in theory be an accurate account of what happened after the incident
occurred, rather than a subjective opinion or belief about what happened, or what occurred to
beyond the immediate. Sixty-one of these papers reported counts on the outcomes and
consequences of interest in this review, as well as a total incident count.
Data source
There were 13 different sources of consequences data. The most predominant of these were
incident forms (n=46 studies used this method), followed by the SOAS/SOAS-R (Staff
Observation Aggression Scale) [Nijman et al. 1999;Palmstierna and Wistedt 1987]
instrument (n=19), qualitative follow-up interviews (which were carried out either
immediately after the incident or soon after) (n=14), official records (clinical, legal, and/or
case records) (n=18), study-specific questionnaires (n=9), OAS/MOAS ([Modified] Overt
Aggression Scale) [Knoedler 1989] (n=9), ASAP (Assaulted Staff Action Program)
(Flannery, 1999) (n=8), video recording (n=3), participant/non-participant observation (n=2),
the Attacks scale [Bowers et al. 2002] (n=2), medical claim documents (n=1), case studies
(n=1), the IES-R instrument (Impact of Events Scale - Revised) [Weiss and Marmar 1997]
(n=1), and supervisory logs (n=1).
Countries
Consequences data was collected from 15 different countries. These were: USA (n=44
studies), UK (n=27), Australia (n=10), Sweden and Canada (both n=5), Italy (n=4), Norway
(n=3), Germany and Netherlands (both n=2), and Denmark, Spain, Sri Lanka, Switzerland,
New Zealand, and Bahrain (all n=1).
Study settings
Thirty-seven studies collected consequences data from inpatient acute settings and thirty
seven studies collected data from mixed settings. Twenty-five studies collected data from
forensic settings, 5 from Psychiatric Intensive Care Units (PICU), two from rehabilitation
units and 2 from veteran settings.
Perspective
One hundred and five studies collected data based on represented the staffs perspective of
the consequence (103 of which collected data solely from this perspective), 3 studies included
data from the perspective of the video camera (2 exclusively), one study analysed the patients
perspective (as well as the staffs perspective), and one study documented a researchers
perspective.
5.2 Findings
A thematic analysis of the consequences data produced 67 distinct lower-level themes
which formed 8 higher-level themes: physical injury, severity of injury, containment/staff
response, patient transferred/discharged, victim psychological outcome, victim
behavioural outcome, property/object damage, and no consequence. Please see Table 1
for a full breakdown of these themes.
Physical injury
Sixty-one studies (56.5%) reported this higher-level theme as an outcome of

violence/aggression. This included 19 lower-level themes that related to different types of
physical injury for the assailant or victim(s) (see table 1).
The majority of these studies (n=32) did not specify the nature of the physical injury as a
consequence of violence/aggression [Abeyasinghe and Jayasekera 2003;Bowers et al.
2002;Carton and et al. 2003;Casseem 1984;Cheung et al. 1996;Cheung et al. 1997;Crowner
et al. 1991;Crowner et al. 1994;Dietz and Rada 1982;Dowson et al. 1999;Flannery, Jr.
2008;Flannery, Jr. and Walker 2008;Grassi et al. 2001;Gudjonsson et al. 2004;Hamadeh et al.
2003;Helmuth 1994;Kennedy et al. 1995;Ketelsen et al. 2007;Larkin et al. 1988;Mellesdal
2003;Nijman et al. 1997;Nijman and Rector 1999;Palmstierna et al. 1991;Palmstierna and
Wistedt 1987;Palmstierna and Wistedt 1995;Powell et al. 1994;Rasmussen and Levander
1996;Reid et al. 1985;Steinert et al. 1999;Stockman and Heiber 1980;Torpy and Hall 1993].
Twenty-eight studies specified the nature of the injury, including head injuries which was
reported as a consequence by seven studies. A retrospective study of two Norwegian acute
psychiatric inpatient wards over a seven year period found that 38.1% of 507
violent/aggressive incidents resulted in head injuries [Langsrud et al. 2007]. Another
retrospective study of injury reports over a five year period in a US-based, large, all-male,
forensic hospital revealed that from 236 staff injuries, 70.7% of them were head injuries
[Carmel and Hunter 1993]. The same authors also found in an earlier study of staff injuries
within a state hospital that over the course of a year, 75.5% of all injuries sustained during a
patient assault (49 injuries in total) resulted in head injuries, while 8.6% of all injuries
sustained during containment procedures (86 injuries in total) resulted in head injuries
[Carmel and Hunter 1989]. Another US-based retrospective study of injury reports, which
aimed to replicate the previously referenced study, found that 39% of all injuries sustained
during a patient assault (31 injuries in total) resulted in head injuries, while 20% of all
injuries sustained during containment procedures (15 injuries in total) resulted in head
injuries [Hanson and Balk 1992]. Another US-based study retrospectively examined data
from the Assaulted Staff Action Program (ASAP) and found that over a one year period,
7% of 193 staff assaults (within a mixture of psychiatric inpatient settings) resulted in head
and back injuries [Flannery, Jr. et al. 2003]. A 15 year retrospective analysis of the same data
source found that 10.2% of 460 staff assault incidents within acute psychiatric inpatient
settings resulted in head and back injuries [Flannery, Jr. et al. 2007]. A 6 month prospective
study of a female observation ward in a Northern Irish General Psychiatric Hospital found
Table 1: Thematic analysis of consequences
PATIENT VICTIM VICTIM

CONTAINMENT/
PHYSICAL INJURY TRANSFERRED/ PSYCHOLOGICAL BEHAVIOURAL
STAFF RESPONSE
DISCHARGED OUTCOME OUTCOME

PROPERTY / OBJECTS DAMAGE

Unspecified physical Seclusion Transfer to higher Irritability Staff fatigue
injury Manual restraint security ward Muscle tenseness Staff alcohol use
Head injury Oral medication Transfer to jail Intrusive thoughts Staff smoked
Back/spine/trunk Intra-muscular Transfer to another Ruminated about Staff ate more/ lost
SEVERITY OF INJURY
injury medication hospital/unit incident appetite
NO CONSEQUENCE
Injury to extremities Time out/patient Transfer to PICU Anger Staff resigned
Facial/eye injury removed from situation Criminal reconviction/ Resentment Debriefing/review
Injury to limbs Verbal de-escalation prosecution Staff fear of patient Strained family
Soft tissue/muscle Staff counselled Decreased job relationships
injury assailant after incident satisfaction Counselling
Abdominal injury ended Dreamt about Support group
Sprain/strain/ Mechanical restraint incident/ sleep meetings
soreness Contacted police disturbances
Scratched/cut/ Constant special Repression
grazed/nosebleed observation Anxiety
Bump/ knock/ bruise Patient denied some of Acute stress disorder
Bone injury their privileges PTSD symptoms
Serious open wound/ Ward doors locked Disruption in domain
laceration Patient detained in of mastery
Burned hospital Disruption in domain
Loss of Staff confronted patient of attachment
consciousness/ Nursing management Disruption in domain
concussion plan reviewed of meaning
Biting injury
Pain lasted <10mins
Pain lasted >10mins
Headache
that out of 208 incidents, there was only one head injury sustained when a patient
intentionally struck their head on a wall during a violent episode [Cooper et al. 1983].
Eight studies reported a back/spine/trunk injury as a consequence of an incident

including six studies previously mentioned: one which revealed that 22.1% of 507
violent/aggressive incidents resulted in head injuries [Langsrud et al. 2007]; one
which found that 13.3% and 6.7% of 236 staff injuries resulted in spinal and trunk
injuries respectively [Carmel and Hunter 1993]; another which found that 12.2% of
all injuries sustained during a patient assault (49 injuries in total) resulted in head
injuries, while 16.2% of all injuries sustained during containment procedures (86
injuries in total) resulted in spinal injuries [Carmel and Hunter 1989]; the replication
study which found that found that 29% of all injuries sustained during a patient
assault (31 injuries in total) resulted in trunk injuries, while 67% of all injuries
sustained during containment procedures (15 injuries in total) resulted in injuries to
trunk or extremities [Hanson and Balk 1992]; another which revealed that 7% of 193
staff assaults (within a mixture of psychiatric inpatient settings) resulted in head and
back injuries [Flannery, Jr. et al. 2003]; a 15 year retrospective analysis of the same
data source found that 10.2% of 460 staff assault incidents within acute psychiatric
inpatient settings resulted in head and back injuries [Flannery, Jr. et al. 2007]. A
Canadian-based retrospective study of staff injuries in a 500 bed forensic psychiatric
service found that over a seven year period, found that incidents that resulted in
injuries to major joints (including the neck and back) were significantly more likely to
result in lost work days than injuries to other body parts [Harris et al. 1986]. Finally, a
UK-based study of staff from an inpatient acute psychiatric unit found that over the
course of 6 months, face or trunk injuries were the result of having been slapped or
punched [Whittington and Wykes 1989].
Five studies cited injury to extremities as a consequence of a violent/aggressive

incident. A retrospective study of two Norwegian acute psychiatric inpatient wards
over a seven year period found that 52.7% and 13.6% of 507 violent/aggressive
incidents resulted in injuries to the upper and lower extremities respectively
[Langsrud et al. 2007]. As previously mentioned, a US-based study found that while
67% of all injuries sustained during containment procedures (15 injuries in total)
resulted in injuries to trunk or extremities [Hanson and Balk 1992]. The study of
which the latter replicated also reported this theme: specifically that over the course of
a year, 6.1% of all injuries sustained during a patient assault (49 injuries in total)
resulted in injuries to the extremities, while 67.4% of all injuries sustained during
containment procedures (86 injuries in total) resulted in injuries to the extremities
[Carmel and Hunter 1989]. The same authors later study found that 9.3% of 236 staff
injuries resulted in injuries to the extremities [Carmel and Hunter 1993]. Finally, a
prospective study conducted at a 23 bedded US-based acute psychiatric female unit
during a six month period reported that from 87 incidents, injuries occasionally
included contusions of an extremity.
One US-based study of patient assault cited facial and eye injuries as a consequence
of violence [Lanza 1988] specifically numbness on parts of the face, black eyes,
and eye injuries. Another study retrospectively investigated staff injuries over a two
year period in one Australian psychiatric hospital and found that 1.9% of 328
incidents resulted in eye injuries, while 0.4% of 328 incidents results in teeth being
knocked out [Grainger and Whiteford 1993]. This study also specified injuries to
limbs as a consequence specifically that 12.3% of 328 incident resulted in twisted
limb injuries. The Canadian-based retrospective study of staff injuries in a 500 bed
forensic psychiatric service found that over a seven year period, found that incidents
that resulted in injuries to major joints (including knee injuries) were significantly
more likely to result in lost work days than injuries to other body parts [Harris et al.
1986]. The two aforementioned ASAP studies also referred to this type of injury
specifically that 5.8% of 460 staff assault incidents within acute psychiatric inpatient
settings resulted in bone/tendon/ligament injuries [Flannery, Jr. et al. 2007] and that
3% of 193 staff assaults (within a mixture of psychiatric settings) resulted in
bone/tendon/ligament injuries [Flannery, Jr. et al. 2003]. Finally, a US-based 6 month
prospective study of repeatedly assaultive psychiatric inpatients found that 21 of 497
recorded incidents resulted in serious injuries such as severe lacerations, fractures,
suspected fractures, burns or dislocations) [Convit et al. 1990].
Another specified type of injury from inpatient assaults were soft tissue/muscle
injuries. These injuries were cited by four studies including one case study of an
aggressive and self-harming patient in a US-based psychiatric hospital who caused 25
injuries to nursing staff over a 39 month study period which included muscle injuries
[Bisconer et al. 2006]. Both previously mentioned ASAP studies cited this injury type
- specifically that 46.3% of 460 staff assault incidents within acute psychiatric
inpatient settings resulted in soft tissue injuries [Flannery, Jr. et al. 2007] and that
52% of 193 staff assaults (within a mixture of psychiatric settings) resulted in soft
tissue injuries [Flannery, Jr. et al. 2003]. An earlier study by the same lead author
conducted a preliminary evaluation of ASAP and found that out of 67 reported
assaults upon psychiatric nursing staff over a 90 day period, 34% resulted in soft
tissue injuries [Flannery et al. 1991]. Abdominal injuries were also cited by two of
the ASAP studies specifically as an outcome for 0.4% of 193 assaults [Flannery, Jr.
et al. 2003] and 1.8% of 460 assaults [Flannery, Jr. et al. 2007].
A number of studies did not explicitly specify the area of the physical injury, but did
refer to sprains, strains, and/or soreness. This included a one year study of a US-
based Veterans unit in which 12.5% of 40 incidents resulted in to sprains/strains
[Murray and Snyder 1991], a study of patient assaults over a 27 month period in a
Canadian psychiatric hospital reported that most of the 201 recorded
violent/aggressive incidents resulted in lacerations, bruising and sprains [Cooper and
Medonca 1991]. A US-based study of nursing staff characteristics related to patient
assault reported that over a 1 year period, reported soreness as a consequence of
violence [Lanza et al. 1991], while another US-based study of violence within a
locked university-based short-term Forensic inpatient unit reported that 45% of staff
injuries (n injuries or incidents not stated) resulted in sprains or strains [Lam et al.
2000]. A retrospective study of patterns of aggression in an Australian forensic
psychiatric hospital reported that mild-moderate injuries such as bruises, sprains, or
welts occurred in 20.3% of 197 incidents [Daffern et al. 2003],
Nine studies cited a physical injury as being scratched/cut/grazed/having a nose-

bleed. This included the previously mention Australian-based retrospective study
which found that 20% of 328 incidents resulted in staff being scratched, cut or grazed
over a two year period at a psychiatric hospital [Grainger and Whiteford 1993]. A 12
month study of violent incidents in a Swedish inpatient psychiatric ward revealed that
in 9.8% of 41 violent incidents, staff suffered bruises or minor wounds [Omerov and
Wistedt 1997]. The previously cited US-based study of a Veterans unit found that
10% of incidents resulted in to scratches or cuts [Murray and Snyder 1991]. A
prospective two year study of the nature of accidents in a 2400 patients from a US-
based psychiatric hospital reported that the majority of the injury reports concerned
trivial injuries such as cuts [Abbott 1978]. Another US-based study examined data
from video cameras and incident reports over a 27 month period within one inpatient
acute psychiatric ward and reported that from 149 incidents, there was 1 incident of a
staff member suffering from a nose bleed after an incident, and that the rest of minor
injuries suffered were predominantly scratches [Crowner et al. 1994]. A 15 year
retrospective analysis of the ASAP found that 12.4% of 460 staff assault incidents
within acute psychiatric inpatient settings resulted in open wounds, scratches, or
spitting incidents [Flannery, Jr. et al. 2007]. A US-based study of patient assault
reported that most staff assaults were judged to be minor such as cuts and scratches
[Lanza 1988]. A Canadian-based study of violent incidents patterns in a general
psychiatric hospital also reported that 5% of injuries from 133 violent incidents
resulted in scratches [Tam et al. 1996]. Finally, a previously cited US-based study of
violence within a locked university-based short-term Forensic inpatient unit reported
that 9% of staff injuries (n injuries or incidents not stated) resulted in abrasions or
scratches [Lam et al. 2000].
The latter study was one of 11 studies that made referenced to bumps, bruises and/or
knocks as a consequence of a violent/aggressive incident. It stated that 32% of staff
injuries resulted contusions or bruises. As previously mentioned, a retrospective study
of patterns of aggression in an Australian forensic psychiatric hospital reported that
mild-moderate injuries such as bruises, sprains, or welts occurred in 20.3% of 197
incidents [Daffern et al. 2003]. Also previously mentioned, an Australian-based
retrospective study found that 3.2% of 328 incidents resulted in staff being knocked or
pushed to the floor over a two year period at a psychiatric hospital [Grainger and
Whiteford 1993]. A 12 month study of violent incidents in a Swedish inpatient
psychiatric ward revealed that in 9.8% of 41 violent incidents, staff suffered bruises or
minor wounds [Omerov and Wistedt 1997], while a one year study of a US-based
Veterans unit reported that 27.5% of 40 incidents resulted in to bruising [Murray and
Snyder 1991]. A prospective two year study of the nature of accidents in a 2400
patients from a US-based psychiatric hospital reported that the majority of the injury
reports concerned trivial injuries such as bruising [Abbott 1978], while a UK-based
study which studied physical assaults in a psychiatric unit of a general hospital found
that over a 12 month period 15 victims sustained mild bruising from 37 incidents
[Edwards et al. 1988]. A study that preliminarily evaluated the data collected during
ASAPs first 90 days reported that the type of staff injury most often sustained were
bruises with swelling (37% from 67 recorded assaults) [Flannery et al. 1991]. A UK-
based exploratory study of coping strategies used by staff in an acute psychiatric
inpatient unit following a patient assault reported that some assaults over a 3 week
period resulted in bruises or swelling [Whittington and Wykes 1991]. As previously
stated, a study of patient assaults over a 27 month period in a Canadian psychiatric
hospital reported that most of the 201 recorded violent/aggressive incidents resulted in
lacerations, bruising and sprains [Cooper and Medonca 1991]. Finally, a US-based
study of nursing staff characteristics related to patient assault reported that over a 1
year period, most reported assaults were judged as minor, many of which were cuts,
scratches, soreness, and/or bruises [Lanza et al. 1991]. Five of the aforementioned
studies reported the total number of violent/aggressive incidents as well as the total
number of bumps/bruises/knocks from these incidents. From this data, a mean and
standard deviation bumps, bruises and/or knocks data was calculated (see table 2).
Table 2: Bumps/bruises/knocks rate data
N bumps/ % bumps/
Study authors N Incidents
bruises/knocks bruises/knocks
Daffern et al (2003) 197 40 20.30%
Grainger & Whiteford (1993) 328 13 4%
Omerov & Wistedt (1997) 24 4 16.7%
Murray & Snyder (1991) 40 11 27.5%
Edwards et al (1988) 37 15 40.5%
Flannery et al (1991) 67 25 37.3%
Mean (SD) 115.5 (122) 18 (12.7) 15.6%
Six studies reported a bone injury as a consequence to aggression/violence. This

included a retrospective study of staff injuries over a two year period in one
Australian psychiatric hospital in which 1.1% of 328 incidents resulted bone fractures
or suspected fractures [Grainger and Whiteford 1993]. A retrospective study of two
Swedish psychosis wards reported that from the 7 (17%) incidents in which the staff
member was seriously injured, the most serious injuries included a finger fracture and
a fracture of the coccyx [Omerov et al. 2004]. lacerations and muscle injuries.
Another study presented a case study of an aggressive and self-harming patient in a
US-based psychiatric hospital who caused 25 injuries to nursing staff over a 39 month
study period which included bone fractures [Bisconer et al. 2006]. Two of the
aforementioned ASAP studies also referred to this type of injury specifically that
5.8% of 460 staff assault incidents within acute psychiatric inpatient settings resulted
in bone/tendon/ligament injuries [Flannery, Jr. et al. 2007], and that over a one year
period, 3% of 193 staff assaults resulted in bone/tendon/ligament injuries [Flannery,
Jr. et al. 2003]. Finally, a US-based 6 month prospective study of repeatedly
assaultive psychiatric inpatients found that 21 of 497 recorded incidents resulted in
serious injuries including bone fractures and suspected fractures [Convit et al.
1990].
A serious open wound/laceration was reported to be a consequence of

violence/aggression by six studies, including the latter study. Further, a case study of
an aggressive and self-harming patient in a US-based psychiatric hospital was
reported to cause an unspecified number of lacerations to staff [Bisconer et al. 2006].
Further, a retrospective examination of ASAP data found that 9% of 193 staff assaults
over a one year period resulted in an open wound injury [Flannery, Jr. et al. 2003]. A
Canadian-based, prospective 27 month study of patient assaults in a psychiatric
hospital reported that most of the 201 recorded violent/aggressive incidents resulted in
lacerations, bruising and sprains [Cooper and Medonca 1991]. Another US-based 6
month prospective study of severely disturbed female patients at a 23 bed psychiatric
unit reported that out of 87 violent incidents, staff injuries were primarily lacerations
[Ionno 1983]. Finally, a prospective 6 month observational study of a female
observation ward in a Northern Irish general psychiatric hospital reported one serious
injury where a patient intentionally struck their head on wall and sustained a serious
laceration but no fracture [Cooper et al. 1983].
Two studies reported that victims of the staff assaults suffered from burn injuries:
one which retrospectively investigated staff injuries over a two year period in an
Australian psychiatric hospital that found that 1.9% of 328 incidents resulted in this
injury [Grainger and Whiteford 1993]; and one which prospectively studied of
repeatedly assaultive inpatients which reported that 4.2% of 497 recorded incidents
resulted in serious injuries such as burns [Convit et al. 1990]. The former study also
reported that 3.2% of 328 incidents were biting injuries and that 1.9% of 328
incidents resulted in a loss of consciousness or concussion. The aforementioned case
study of an aggressive and self-harming patient in a US-based psychiatric hospital
also reported concussion as a consequence of violence/aggression [Bisconer et al.
2006].
Four studies reported that the incurred physical injury resulted in less than 10
minutes of pain while two of these studies also reported that the injury resulted in
more than 10 minutes of pain. Specifically, one study which examined aggression
among psychiatric inpatients in Australian rehabilitation wards found that 7.6% of
806 incidents resulted in pain lasting up to 10 minutes only, and that 2.6% of these
incidents resulted in pain lasting more than 10 minutes [Cheung et al. 1996]. A study
of aggressive behaviour in UK acute psychiatric wards reported that 2.3% of 264
aggressive incidents resulted in pain for the victim that lasted less than 10 minutes
incidents, whereas in 1.9% of these incidents the pain lasted beyond 10 minutes
[Foster et al. 2007]. A retrospective study of two Norwegian acute psychiatric
inpatient wards over a seven year period found that 59% of 507 violent/aggressive
incidents resulted in injuries that resulted in less than 10 minutes of pain [Langsrud et
al. 2007]. A retrospective study of two Norwegian acute psychiatric inpatient wards
over a seven year period found that 38.1% of 507 violent/aggressive incidents resulted
in head injuries [Langsrud et al. 2007], while a Swedish study which examined
assaults on staff by acute psychiatric inpatients showed reported that in 95% of 137
incidents, the pain of any injury lasted less than 10 minutes [Omerov et al. 2002].
Developing a headache as a consequence of violence/aggression was cited by three

studies. This included a one year study of a US-based Veterans unit in which 1 of the
40 incidents resulted in a headache for the victim [Murray and Snyder 1991].
Headaches were reported to be one of the most commonly reported symptoms
immediately following an assault on staff at a UK-based acute psychiatric inpatient
unit [Whittington and Wykes 1991] while, a US-based study of patient assault cited
this symptom as a consequence of violence [Lanza 1988].
Severity of physical injury
Thirty-two of the 61 studies which reported a physical injury as a consequence of

violence/aggression also reported the severity of the reported injury. Twenty-three of
these studies reported the number of physical injuries that were classed as minor,
moderate, and/or as a serious injury (see Table 4) [Abeyasinghe and Jayasekera
2003;Brizer et al. 1988;Casseem 1984;Convit et al. 1990;Cooper et al. 1983;Crowner
et al. 1994;Daffern et al. 2003;Daffern et al. 2003;Edwards et al. 1988;Flannery, Jr. et
al. 2007;Foster et al. 2007;Grainger and Whiteford 1993;Kennedy et al. 1995;Maier et
al. 1994;Mellesdal 2003;Miller et al. 1993;Murray and Snyder 1991;Nijman and
Rector 1999;Omerov et al. 2004;Omerov and Wistedt 1997;Palmstierna et al.
1991;Powell et al. 1994;Torpy and Hall 1993], while nine studies did not this
breakdown ([Abbott 1978;Bisconer et al. 2006;Carton and et al. 2003;Cheung et al.
1996;Hodgkinson et al. 1984;Hunter and Love 1993;Joyal et al. 2008;Pearson et al.
1986;Whittington and Wykes 1991]. As can be seen in table 3, eighteen studies
reported both the number of minor/moderate/serious injuries as well as the number of
total recorded injuries. Table 4 examines the differences in rates across settings,
country, and data source after controlling for the total number of violent/aggressive
incidents and physical injuries per study.
Table 3: Severity of injuries rate data
N mild N moderate N serious

Total
severity severity severity
Study authors injuries Setting Country Data source
(% of (% of (% of
recorded
injuries) injuries) injuries)
Netherla
Nijman & Rector (1999) 18 (100%) 18 Acute SOAS-R
nds
Daffern et al (2003) 40 (100%) 40 Forensic Australia Incident forms
Grainger & Whiteford (1993) 36 (7.7%) 465 Acute Australia Incident forms
Omerov et al (2004) 15 (68%) 7 (32%) 22 Acute Sweden Interview
Omerov & Wistedt (1997) 16 (100%) 16 Acute Sweden Official records
Daffern et al (2003) 17 (100%) 17 Forensic Australia Incident forms
Mellesdal (2003) 21 (20%) 106 Acute Norway Official records
Powell et al (1994) 40 (22.7%) 176 Mix UK Incident forms
Kennedy et al (1995) 280 (80.9%) 66 (19.1%) 346 Forensic UK Incident forms
Maier et al (1994) 44 (10.7%) 412 Forensic USA OAS
Murray & Snyder (1991) 19 (70.3%) 5 (18.5%) 3 (11.1%) 27 Veterans USA Observation
Crowner et al (1994) 16 (89%) 1 (5.5%) 1 (5.5%) 18 Acute USA Video recording
Brizer et al (1995) 1 (100%) 1 Acute USA Video recording
Edwards et al (1988) 15 (100%) 15 Mix UK Interview
Convit et al (1990) 21 Not stated Acute USA Incident forms
Foster et al (1994) 13 2 Not stated Acute UK SOAS-R
Torpy & Hall (1993) 20 Not stated Forensic UK Incident forms
Abeyasinghe & Jayasekers (2003) 33 (68.8%) 15 (32.2%) 48 Acute Sri Lanka Study questionnaire
Flannery et al (2007) 170 (37%) 145 (31.5%) 65 (14.1%) 460 Acute USA ASAP
Miller et al (1993) 365 Not stated Mix Australia Incident forms
Palmstierna et al (1991) 31 (94%) 2 (6%) 33 PICU Sweden SOAS
Casseem (1994) 2 Not stated Mix UK Incident forms
Cooper et al (1983) 30 (96.7%) 1 (3.3%) 31 Mix UK Incident forms
Table 4: Injury severity rates
Percentage
Percentage of Percentage of Percentage of Percentage of
of Percentage of
moderate- serious injuries moderate- serious
mild injuries mild injuries
Grouping variable severity per per incident severity per injuries per
per incident per injury (SD)
incident (SD) (SD) injury (SD) injury (SD)
(SD) [n studies]
[n studies] [n studies] [n studies] [n studies]
[n studies]
All studies 26% (18) [13] 11% (10) [5] 6% (6) [18] 85% (20) [13] 19% (30) [3] 35% (52) [13]
Setting: Acute (including PICU) 27% (21) [7] 5% (4) [3] 8% (7) [10] 80% (23) [7] 19% (18) [2] 48% (64) [8]
Setting: Forensic 18% (12) [3] - 4% (3) [3] 94% (11) [3] - 15% (6) [2]
Setting: Mix 27% (18) [2] 28% (-) [1] 2% (2) [3] 98% (2) [2] - 13% (14) [2]
Country: UK 28% (13) [3] 5% (-) [1] 3% (2) [6] 93% (10) [3] - 15% (10) [3]
Country: USA 23% (21) [3] 7% (6) [3] 4% (2) [6] 65% (26) [3] 19% (13) [3] 28% (40) [5]
Country: Australia 13% (11) [2] 28% (-) [1] 5% (8) [2] 100% (-) [2] - 8% (-) [1]
Country: Any other 33% (21) [5] - 13% (8) [4] 86% (16) [5] - 64% (82) [4]
Data source: Incident forms 21% (7) [3] 28% (-) [1] 4% (4) [8] 93% (10) [3] - 13% (9) [4]
Data source: SOAS/R 24% (14) [3] 5% (-) [1] 7% (9) [3] 87% (17) [3] - 19% (18) [2]
Data source: Any other 30% (23) [7] 7% (6) [3] 7% (7) [7] 81% (24) [7] 19% (13) [3] 51% (68) [7]
Rates of physical injuries
Thirty studies reported the total number of violent/aggressive incidents as well as the
total number of the physical injuries resulting from these incidents. The mean number
of violent/aggressive incidents among these studies was 548 (SD=679), and the mean
number of physical injuries was 148 (SD=183). As can be seen in table 5, the mean
number of violent/aggressive incidents per study was substantially higher within
forensic studies compared to acute and other settings. It also shows that the mean
number of physical injuries per study within forensic settings is slightly higher than in
acute settings. However, the likelihood of experiencing a physical injury as a
consequence of an incident is nearly twice as high within acute settings compared to
forensic settings, but similar to mixed settings. The mean number of recorded
incidents and physical injuries was found to similar across countries. However, the
likelihood of experiencing a physical injury during an incident was revealed to be
higher within Australia and other non-UK and non-USA countries. The mean number
of physical injuries was more than twice the number within incident forms compared
to the SOAS/R and other forms of data sources, while the mean number of physical
injuries was also higher within incident forms compared to all other sources.
However, the likelihood of experiencing a physical injury during an incident was
revealed to be fairly similar across data sources.
Table 5: Rates of physical injury
Percentage of
injuries controlling
Mean (SD)
Mean (SD) Incidents for incidents
Grouping variable Physical Injuries
[n studies] (injuries N / Incident
[n studies]*
N * 100)
[n studies]*
All studies 521 (583) [61] 148 (183) [30] 37% (35) [30]
Setting: Acute (including PICU) 345 (408) [27] 166 (217) [13] 43% (44) [13]
Setting: Forensic 907 (814) [16] 201 (199) [8] 23% (15) [8]
Setting: Mix 441 (419) [15] 88 (77) [7] 40% (32) [7]
Setting: Any other 441 (384) [3] 20 (11) [2] 35% (46) [2]
Country: UK 501 (549) [19] 107 (127) [7] 29% (17) [7]
Country: USA 690 (788) [15] 193 (198) [10] 35% (31) [10]
Country: Australia 631 (448) [8] 134 (221) [4] 43% (66) [4]
Country: Any other 362 (462) [19]] 135 (205) [9] 41% (37) [9]
Data source: Incident forms 716 (656) [25] 227 (170) [10] 34% (39) [10]
Data source: SOAS/R 306 (236) [17] 131 (249) [6] 40% (45) [6]
Data source: Any other 457 (637) [19] 98 (151) [14] 37% (29) [14]
* = only studies which reported physical injuries were included in calculation
Containment/staff response
Half of all studies with consequences/outcomes data reported 15 different types of

containment/staff responses in relation to violence/aggression (n=54, 50%).
Thirty nine studies (36.1%) reported seclusion as a consequence of

violence/aggression. Twenty two of these studies did not report the total number of
seclusion episodes as well as the total number of violent/aggressive incidents. This
included a US-based study of repeated inpatients assaults within a Veterans hospital
which found that measures such as seclusion, transfer to a maximum-security
treatment program, or transfer to jail for confinement were used in 4.7 % of 422
assaults [Blow et al. 1999]. Another US-based study that investigated the relationship
between psychopathy and violence in a forensic setting and reported that 17% of their
patient sample were either secluded or restrained in the first 2 months of
hospitalisation while 8.5% of their sample were either secluded or restrained in the
last 2 months of hospitalisation [Heilbrun 1998]. Another US-based study that
revealed that violent inpatients within acute settings are significantly more frequently
secluded than non-violent patients [Krakowski and Czobor 1997]. An exploratory
investigation into the nursing management of aggression in Australian acute
psychiatric settings found that patients were secluded after 61% of incidents (although
the total number of incidents was not reported) [Delaney et al. 2001], while a
retrospective UK-based study of the management of psychiatric inpatient violence
found that black patients were more likely than white patients to be secluded after a
violent incident (however, these differences disappeared when other variables were
considered), and that the strongest predictors of seclusion were the gender of patient,
nurse being a target, patient being rated as agitated, extent of injury, age of patient and
being on a civil section [Gudjonsson et al. 2004]. A US-based study of staff injuries
and violence in a forensic psychiatric setting reported that restraints were used were in
48% of seclusion episodes [Morrison et al. 2002], while the same lead author in an
earlier 7 month, observational study of violent psychiatric inpatients at a public
hospital reported that seclusion was used on a daily basis and that it was common for
several patients to be in seclusion at the same time [Morrison 1990]. A UK-based
study of physical assaults in a general hospital psychiatric unit revealed that some
degree of physical restraint or seclusion (with or without psychotropic drugs) was
exercised after 24 incidents [Edwards et al. 1988], while another UK-based study
found that the combined containment methods of medication, restraint and seclusion
were used in 47% (n=103) cases within one acute psychiatric unit. A US-based study
that examined the relationship of staffing to violence by patients in a forensic setting
found that there were 2,720 (20.6%) instances of interventions to prevent attack such
as seclusion and restraint [Carmel et al. 1991]. A Canadian study examining violence
within forensic settings reported that the likelihood of female (77.8%) and male
(63.3%) patients being placed in seclusion as a result of aggression differed, although
not significantly [Nicholls et al. 2009]. A prospective, 9 month study of aggressive
behaviour in a New Zealand-based acute psychiatric unit reported that all of the 80
aggressive patients (15% of the sample) were secluded at some point during their
admission [El-Badri and Mellsop 2006]. Similarly, all violent patients in a US-based
study of inpatient violence in a maximum security hospital were secluded for their
actions [Dietz and Rada 1982]. Additionally, a retrospective study of reported
incidents over a five and a half year period in a US-based general hospital and a
nursing home found that following a violent incident, an intervention was used in
40% of cases which was most often seclusion, medication, medication and seclusion
[Jones 1985]. Another US-based study of 6 case reports of psychiatric patients
considered what the impact of therapist countertransference was. They reported that
the use of containment was seen to exaggerate the patients dangerousness as violence
grew once in they were in seclusion [Lion and Pastermak 1973]. Another US-based, 6
month prospective study of severely disturbed female patients at a 23 bed acute
psychiatric unit reported that seclusion was used more with psychotic patients than
other patients [Ionno 1983]. A German study of aggressive behaviour among first
admission patients with schizophrenia at a general psychiatric hospital reported 22%
of these patients were placed in seclusion as a consequence of aggression during their
admission [Steinert et al. 1999]. An Australian-based prospective, 7 month study of
violent incidents within inpatient psychiatric settings reported that non-recidivist
patients were more likely to be secluded after an incident [Owen et al. 1998]. A
retrospective study of aggression in an Australian forensic psychiatric hospital that
reported 253 seclusion episodes out of 197 incidents (128%) over the course of a year
[Daffern et al. 2003].A study of 40 hospital wards in the USA and Canada were
surveyed during specified periods for 1 year to document assaults by inpatients on
staff or other pts. They revealed that about two thirds of all incidents led to seclusion
or restraint [Reid et al. 1989]. Additionally, a UK-based study on the development of
the 'attacks' scale (attempted and actual assault scale) revealed that within acute
psychiatric services, only 2 incidents of seclusion were reported in response to
violence (total number of incidents not stated) [Bowers et al. 2002]. Finally, 54% of
violent patients in a forensic hospital were secluded in a 6 month prospective study
[Larkin et al. 1988].
Sixteen studies reported the total number of seclusion episodes as well as the total
number of violent/aggressive incidents. The highest rate of seclusion was reported by
a UK-based retrospective study of violent incidents on two PICUs in which 87% of
116 incidents resulted in the patient being secluded following an incident over a
course of one year [Coldwell and Naismith 1989]. The next highest rate was
substantially lower: 49% of 164 incidents in a Dutch acute psychiatric admissions
ward over a 24 week period [Nijman et al. 1997]. Seclusion was used in 26% of 536
incidents over a 3 year period in a US-based medium secure unit [Parkes 2003], 25%
of 264 incidents over a 10 month period in 5 UK-based acute wards [Foster et al.
2007], 20.6% of 331 incidents over a 6 month period in an Australian forensic
psychiatric hospital [Daffern et al. 2003], 18% of 257 incidents over a 6 month period
in a Canadian maximum security hospital [Joyal et al. 2008], 16% of 50 incidents
over a 6 month period in three Australian forensic wards [Daffern et al. 2003], and
15% of 208 incidents over a 6 month period in a female observation ward within a
Northern-Irish general psychiatric hospital [Cooper et al. 1983]. It was also used in
15% of 820 incidents over a 3 year period in a UK-based medium secure unit [Torpy
and Hall 1993], 14% of 760 incidents in 24 Swiss-based acute psychiatric wards
[Abderhalden et al. 2007], 13% of 512 incidents over a 7 year period in two
Norwegian acute psychiatric wards [Langsrud et al. 2007], 13% of 441 incidents over
a 1 year period in a German general psychiatric hospital [Ketelsen et al. 2007], 12%
of 963 incidents in 2 UK-based forensic and 1 UK-based PICUs [Mills 1997], 6% of
1289 incidents over a 3 month period in 2 units located in an Australian primary
psychiatric hospital and a 6 month period in 3 acute psychiatric units of an Australian
general hospital [Owen et al. 1998], 4% of 2180 incidents in a UK-based medium
secure unit [Gudjonsson et al. 2000] and 2% of 130 incidents over a 5 month period in
a large NHS psychiatric hospital [Shepherd and Lavender 1999].
Seclusion rate
Using the total number of seclusion episodes as well as the total number of
violent/aggressive incidents reported in the above seventeen studies, a percentage
statistic representing the likelihood of incident resulting in seclusion was calculated.
Across all studies which reported at seclusion use (as well as the total number of
violent/aggressive incidents), the mean percentage of this statistic was found to
20.89% (SD = 20.7) (see table 5). Table 6 also shows that that the mean number of
seclusion episodes per study within forensic settings is slightly higher than in acute
settings and more than twice as high compared to other settings. However, the
likelihood of a patient experiencing seclusion as a consequence of an incident is more
than twice as high within acute settings compared to forensic settings, and even higher
compared to mixed settings. The mean number of recorded seclusion episodes and the
likelihood of experiencing seclusion as a consequence of violence/aggression was
found to be slightly lower within Australia compared to the UK and other countries.
Additionally, both the mean number of recorded seclusion episodes and the likelihood
of experiencing seclusion as a consequence of violence/aggression were found to be
very similar between incident forms and SOAS/R data sources.
Table 6: Rates of seclusion
Percentage of
Mean (SD) seclusions controlling
Mean (SD) Incidents
Grouping variable Seclusion episodes for incidents (seclusion
[n studies]
[n studies]* N / Incident N * 100)
[n studies]*
All studies 516 (584) [61] 76 (36) [16] 21% (21) [16]
Setting: Acute (including PICU) 345 (408) [27] 84 (21) [5) 38% (31) [5]
Setting: Mix 441 (419) [15] 42 (33) [4] 9% (6) [4]
Country: UK 501 (549) [19] 74 (44) [7] 23% (29) [7]
Country: Any other 506 (639) [34] 83 (36) [6] 22% (14) [6]
* = only studies which reported seclusion episodes were included in calculation
Another containment method in response to violence/aggression was manual

restraint (non-mechanical) which was reported by twenty-three studies (21.3%), six
of which did not report the total number of restraint episodes as well as the total
number of violent/aggressive incidents [Gudjonsson et al. 2000] [Edwards et al.
1988] [Duxbury 2002] [Omerov et al. 2002] [Bowers et al. 2002] [Harris et al. 1986].
Eighteen studies did report the total number of physical restraint episodes as well as
the total number of violent/aggressive incidents. The highest rate of manual restraint
was reported to be 84% of 507 incidents over a seven year period in two Norwegian
acute psychiatric inpatient wards [Langsrud et al. 2007]. The next highest rate of
restraint was found to be 78% of 116 incidents over a course of a year within two UK-
based PICUs [Coldwell and Naismith 1989], followed by 76% of 1144 incidents over
a 6 month period within one UK-based forensic hospital [Larkin et al. 1988], 67% of
2180 incidents over a 17 year period in a UK- based medium secure unit [Gudjonsson
et al. 2000], and 57% of 3874 incidents within UK-based general psychiatric units
across 10 NHS trusts [Dowson et al. 1999]. Additionally, restraint was used in 38% of
130 incidents over a 5 month period within a large NHS psychiatric hospital
[Shepherd and Lavender 1999], 38% of 477 incidents over an eight week period
within 11 Australian-based psychiatric rehabilitation wards [Cheung et al. 1997], 36%
of 981 incidents over a 4 year period within a UK-based forensic unit [Kennedy et al.
1995], 33% of 124 incidents over a 9 month period in a New Zealand-based acute
psychiatric unit [El-Badri and Mellsop 2006] and 26% of 355 incidents over the
course of a year within one UK-based general psychiatric hospital [Tobin et al. 1991].
Lower physical restraint rates were reported to be 21% of 409 incidents over a 7 year
period within one Italian 15-bed acute inpatient unit [Grassi et al. 2006], 19% of 1289
incidents over a 3 month period in 2 units located in an Australian primary psychiatric
hospital and a 6 month period in 3 acute psychiatric units of an Australian general
hospital [Owen et al. 1998], 17% of 441 incidents over a 1 year period in a German
general psychiatric hospital [Ketelsen et al. 2007], 17% of 963 incidents in 2 UK-
based forensic and 1 UK-based PICUs [Mills 1997], and 12% of 820 incidents over a
3 year period in a UK-based medium secure unit [Torpy and Hall 1993]. The lowest
reported physical restraints were reported to be 10% of 264 incidents over a 10 month
period in 5 UK-based acute wards [Foster et al. 2007], 5% of 257 incidents over a 6
month period in a Canadian maximum security hospital [Joyal et al. 2008] and finally
3% of 806 incidents over an 8 week period within Australian rehabilitation wards
[Cheung et al. 1996].
Manual restraint rate
Using the total number of physical restraint episodes as well as the total number of
violent/aggressive incidents reported in the above twenty studies, the percentage of
incidents resulting in the use of physical restraint was calculated. Across all studies
which reported
physical restraint (as well as the total number of violent/aggressive incidents), the
mean percentage of this rate was found to be 34.25% (SD = 26.8) (see table 7). When
settings were compared, there was a slightly higher rate of restraint within acute
settings compared to forensic settings, although the rate of physical restraint was
recorded to be much higher when incident forms were used, compared to the SOAS/R
tool. The majority of the studies were UK based (n=10), while 3 were Australia based,
2 from were based in Italy, and 1 from Canada, Germany, and Norway. The mean
number of restraint episodes within UK-based studies was found to be 343 (SD=465),
with a rate of 41.69% (SD=26) when controlling for incidents.
Table 7: Rates of manual restraint

Percentage of
restraint episodes
Mean (SD)
controlling for
Mean (SD) Incidents physical restraint
Grouping variable incidents (physical
[n studies] episodes
restraint N / Incident N
[n studies]*
* 100)
[n studies]*
All studies 521 (583) [61] 240 (371) [18] 34% (27) [18]
Setting: Mix 441 (419) [15] 136 (89) [5] 31% (16) [5]
* = only studies which reported manual restraint episodes were included in calculation
Another containment method in response to inpatient violence/aggression was

revealed to be the use of oral medication. Twenty-seven studies (25%) reported this
containment method, eight of which did not report the total number of incidents in
which oral medication was used as well as the total number of violent/aggressive
incidents [Delaney et al. 2001] [Morrison 1990] [Abderhalden et al. 2007] [Nicholls
et al. 2009] [Jones 1985] [Ionno 1983] [Owen et al. 1998] [Bowers et al. 2002].
Eighteen studies reported the total number of incidents in which oral medication was
used as well as the total number of violent/aggressive incidents. The highest rate of
oral medication was reported to be 66% of 124 incidents over a 9 month period in a
New Zealand-based acute psychiatric unit [El-Badri and Mellsop 2006], followed by
54% of 477 incidents over an eight week period within 11 Australian-based
psychiatric rehabilitation wards [Cheung et al. 1997], 36% of 2180 incidents in a UK-
based medium secure unit [Gudjonsson et al. 2000], 34% of 264 incidents over a 10
month period in 5 UK-based acute wards [Foster et al. 2007], 34% of 116 incidents
over a course of a year within two UK-based PICUs [Coldwell and Naismith 1989],
and 34% of 41 incidents within two Swedish psychosis wards [Omerov et al. 2004].
The next highest rates were recorded as 28% of 1289 incidents over a 3 month period
in 2 units located in an Australian primary psychiatric hospital and a 6 month period
in 3 acute psychiatric units of an Australian general hospital [Owen et al. 1998], 25%
of 221 incidents within one UK-based mental health unit that comprised of three acute
wards [Duxbury 2002], 24% of 355 incidents over the course of a year within one
UK-based general psychiatric hospital [Tobin et al. 1991], 21% of 806 incidents over
an 8 week period within Australian rehabilitation wards [Cheung et al. 1996], and
21% of 130 incidents over a 5 month period within a large NHS psychiatric hospital
[Shepherd and Lavender 1999]. Lower rates of oral medication use were reported to
be 17% of 409 incidents over a 7 year period within one Italian 15-bed acute inpatient
unit [Grassi et al. 2006], 16% of 257 incidents over a 6 month period in a Canadian
maximum security hospital [Joyal et al. 2008], 13% of 981 incidents over a 4 year
period within a UK-based forensic unit [Kennedy et al. 1995], and 13% of 24
incidents over a 12 month period in one Swedish inpatient psychiatric [Omerov and
Wistedt 1997]. The lowest recorded rates were 9% of 507 incidents over a seven year
period in two Norwegian acute psychiatric inpatient wards [Langsrud et al. 2007], 8%
of 37 incidents over a a one year period in a UK-based psychiatric unit of a general
hospital [Edwards et al. 1988], 7% of 137 incidents over a 3 year period within one
Swedish-based acute psychiatric ward [Omerov et al. 2002], and 3% of 208 incidents
over a 6 month period in a female observation ward within a Northern-Irish general
psychiatric hospital [Cooper et al. 1983].
Oral medication rate
Using the total number of oral medication episodes as well as the total number of
violent/aggressive incidents reported in the above nineteen studies, the percentage of
incidents resulting in the use of oral medication was calculated. Across all studies
which reported oral medication restraint (as well as the total number of
violent/aggressive incidents), the mean percentage of this rate was found to be 24%
(SD = 16) (see table 8). When settings were compared, there was a slightly higher rate
of oral medication within acute settings compared to forensic settings and mixed
settings, while no differences of note were revealed when comparing data sources.
The majority of the studies were UK based (n=9), while 3 were based in Sweden, 3
from Australia, 1 from Italy, Canada, New Zealand, Norway, and Sweden. The mean
number of restraint episodes within UK-based studies was found to be 135 (SD=246),
with a rate of 22% (SD=12) when controlling for incidents.
Another medication-based containment method that was reported by the literature to

be used in response to inpatient violence/aggression was intra-muscular medication.
This was reported by fourteen studies (12.8%) reported this containment method, six
of which did not report the total number of incidents in which intra-muscular
medication was used as well as the total number of violent/aggressive incidents
[Gudjonsson et al. 2004] [Tardiff 1983] [Abderhalden et al. 2007] [Steinert et al.
1999] [Bowers et al. 2002] [Turns and Gruenberg 1973] Omerov, Edman, & Wistedt
2002).
Table 8: Rates of oral medication
Percentage of oral
Mean (SD) medication controlling
Mean (SD) Incidents oral medication for incidents (oral
Grouping variable
[n studies] episodes medication N /
[n studies]* Incident N * 100)
[n studies]*
All studies 521 (583) [61] 111 (183) [19] 24% (16) [19]
Setting: Mix 441 (419) [15] 96 (152) [5] 17% (11) [5]
* = only studies which reported oral medication were included in calculation
Six studies reported the total number of incidents in which intra-muscular medication
was used as well as the total number of violent/aggressive The highest rates of intra-
muscular medication were reported by the same lead author: 46% of 41 incidents
within two Swedish psychosis wards [Omerov et al. 2004], and 29% of 24 incidents
over a 12 month period in a Swedish inpatient psychiatric ward [Omerov and Wistedt
1997]. Lower rates of intra-muscular medication included 16% of 441 incidents over
a 1 year period in a German general psychiatric hospital [Ketelsen et al. 2007], 10%
of 477 incidents over an eight week period within 11 Australian-based psychiatric
rehabilitation wards [Cheung et al. 1997], 3% of 806 incidents over an 8 week period
within Australian rehabilitation wards [Cheung et al. 1996], and 3% of 257 incidents
over a 6 month period in a Canadian maximum security hospital [Joyal et al. 2008].
Intra-muscular medication rate
Using the total number of intra-muscular medication episodes as well as the total
number of violent/aggressive incidents reported in the above six studies, the
percentage of incidents resulting in the use of intra-muscular medication was
calculated. Across all studies which reported this containment method (as well as the
total number of violent/aggressive incidents), the mean percentage of this rate was
found to be 17.91% (SD = 17.1). Country, setting and data source comparisons were
not calculated due to lack of study numbers.
A total of sixteen studies (14.8%) reported time out/patient removed from the
situation. Three of these studies did not report the number of time out episodes as
well as the total number of violent/aggressive incidents [Kennedy et al. 1995]
[Morrison 1990] [Bowers et al. 2002]. Of the 13 which did report these data, the
highest reported rate of time out use was reported to be 45% of 181 incidents over an
eight week period within 11 Australian-based psychiatric rehabilitation wards
[Cheung et al. 1997], followed by 37% of 257 incidents over a 6 month period in a
Canadian maximum security hospital [Joyal et al. 2008], and 27% of 806 incidents
over an 8 week period within Australian rehabilitation wards [Cheung et al. 1996].
Other reported rates included 21% of 1289 incidents over a 3 month period in 2 units
located in an Australian primary psychiatric hospital and a 6 month period in 3 acute
psychiatric units of an Australian general hospital [Owen et al. 1998], 21% of 24
incidents over a 12 month period in one Swedish inpatient psychiatric [Omerov and
Wistedt 1997], 20% of 264 incidents over a 10 month period in 5 UK-based acute
wards [Foster et al. 2007], 15% of 41 incidents within two Swedish psychosis wards
[Omerov et al. 2004], and 14% of 409 incidents within over a 7 year period within
one Italian 15-bed acute inpatient unit [Grassi et al. 2006]. Lower rates of time out
included 11% of 507 incidents over a seven year period in two Norwegian acute
psychiatric inpatient wards [Langsrud et al. 2007], 7% of 164 incidents over a 24
week period in a Dutch-based acute psychiatric admissions ward [Nijman et al. 1997],
7% of 137 incidents over a 3 year period within one Swedish-based acute psychiatric
ward [Omerov et al. 2002], and 5% of 130 incidents over a 5 month period within a
large NHS psychiatric hospital [Shepherd and Lavender 1999]. The lowest reported
rate of time out was found to be 4% of 2180 incidents over a 17 year period in a UK-
based medium secure unit [Gudjonsson et al. 2000].
Time-out/patient removed from the situation medication rate
Using the total number of time out episodes as well as the total number of
violent/aggressive incidents reported in the above eight studies, the percentage of
incidents resulting in the use of time-out was calculated. Across all studies which
reported this containment method (as well as the total number of violent/aggressive
incidents), the mean percentage of this rate was found to be 18.02% (SD = 12.4). The
mean number of time-out episodes within acute-based studies (n=7) was 28.4 (SD =
25.3), while the average rate of use was found to be 13.6% (SD = 5.6). This data
could not be meaningfully compared to forensic (n=2) and other settings (mixed
settings: n=2; rehabilitation settings: n=2). The mean number of episodes recorded by
SOAS/R was found to be 61.63 (SD = 68.8), while the average recorded rate of use
was found to be 18.3% (SD = 12.6). This data source could not be meaningfully
compared to other data sources due to lack of study numbers, while country
comparisons were also not calculated for the same reason.
Another frequently cited containment method was verbal de-escalation which was
reported by 12 studies, 3 of which did not report the number of verbal de-escalation
episodes and/or the total number of violent/aggressive incidents [Kennedy et al. 1995]
[Ionno 1983] [Morrison 1990]. Of the nine studies which did report these data, the
highest reported rate of verbal de-escalation in response to violence/aggression was
reported to be 70% of 806 incidents over an 8 week period within Australian
rehabilitation wards [Cheung et al. 1996]. This containment method was also used for
42% of 264 incidents over a 10 month period in 5 UK-based acute wards [Foster et al.
2007], 35% of 507 incidents over a 7 year period in two Norwegian acute psychiatric
wards [Langsrud et al. 2007], 24% of 41 incidents within two Swedish psychosis
wards [Omerov et al. 2004], 24% of 409 incidents over a 7 year period within one
Italian 15-bed acute inpatient unit [Grassi et al. 2006], 23% of 130 incidents over a 5
month period in one NHS psychiatric hospital [Shepherd and Lavender 1999], and
22% of 221 incidents within one UK-based mental health unit that comprised of three
acute wards [Duxbury 2002]. Verbal de-escalation was least frequently used by two
Swedish-based studies which reported that it was applied in 17% of 24 incidents over
a 12 month period in one inpatient psychiatric [Omerov and Wistedt 1997], and
applied in only 14% of 137 incidents over a 3 year period within one acute psychiatric
ward [Omerov et al. 2002]. The overall mean number of verbal de-escalation
episodes across the aforementioned nine studies was found to be 118 (SD = 176.9),
while the mean rate of verbal de-escalation was found to be 30.1% (SD = 17.4).
It was reported by seven studies that staff counselled the assailant after the incident
ended, four of which did not provide the number of episodes relating to this theme, as
well as the total number of violent/aggressive incidents [Omerov et al. 2004]
[Kennedy et al. 1995] [Owen et al. 1998] [Cheung et al. 1997]. The three studies
which did report these data reported that it was used in 98% of 130 incidents over a 5
month period in a large NHS psychiatric hospital [Shepherd and Lavender 1999], in
47% of 355 incidents over the course of a year within one UK-based general
psychiatric hospital [Tobin et al. 1991], and in 9% of 116 incidents over a course of a
year within two UK-based PICUs [Coldwell and Naismith 1989].
The use of mechanical restraint as a containment strategy for violence/aggression

was reported by nineteen studies (17.6%), five of which reported the total number of
mechanical restraint episodes as well as the total number of violent/aggressive
incidents. The highest reported rate of mechanical restraint was found to be 46.3% of
41 incidents within two Swedish psychosis wards [Omerov et al. 2004], followed by
42% of 24 incidents over a 12 month period in one Swedish inpatient psychiatric
involved the use of mechanical restraint [Omerov and Wistedt 1997]. Another study
revealed that 24% of 441 incidents over a 1 year period in a German general
psychiatric hospital resulted in mechanical restraint [Ketelsen et al. 2007], while
19.6% of 409 incidents over a 7 year period within one Italian 15-bed acute inpatient
unit [Grassi et al. 2006] and 13% of 31 incidents over a 6 month period within one
Italian-based acute psychiatric unit [Troisi et al. 2003] also resulted in this
containment measure. Fifteen studies did not report the total number of mechanical
restraint episodes as well as the total number of violent/aggressive incidents. This
included a Danish study of inpatient acute setting violence which reported that violent
patients were significantly more likely than non-violent patients to be restrained using
a leather belt (55.4% vs. 8.9% respectively; OR=12.72, CI=6.83-23.61) [Benjaminsen
et al. 1996]. A US-based study of violence in a forensic setting found that 39% of
violent incidents resulted in the use of ambulatory restraints and that 13% of incidents
resulted in 4 or 5 point restraints to the bed [Morrison et al. 2002], while another
US-based study found that 17% of patients were either secluded or restrained in the
first 2 months of hospitalisation, and that 8.5% were either secluded or restrained in
the last 2 months of hospitalisation in a forensic hospital [Heilbrun 1998]. Also within
the US, it was revealed that violent inpatient acute patients were significantly more
frequently restrained or secluded than non-violent patients (F=17.24, p=.0001)
[Krakowski and Czobor 1997], while a large-scale 2 month cross-sectional study of a
State hospital system reported that violent patients were likely to have receive
mechanical restraint during previous month [Tardiff 1983]. It was also reported in a
qualitative study that this containment measure is used by nurses in order to
effectively control the ward activities in the most efficient manner possible as they
saw it, and that many staff prefer to deal with situations using physical restraints
rather than taking the time to use verbal techniques [Morrison 1990]. Another US-
based study which retrospectively analysed 6 years of ASAP data revealed that
assaultive personality disorder patients were significantly more frequently required to
be mechanically restrained than assaultive schizophrenic patients [Flannery et al.
2002], while a study examining the relationship of staffing to patient violence over a
56 month period within forensic settings incident reports found that in 36.8% of
aggressive incidents, interventions to prevent attack such as seclusion and restraint
were used by nursing staff [Carmel et al. 1991]. Another US-based forensic-based
study reported that controlling interventions such as mechanical restraint were used
significantly more often for physical aggression towards staff compared to other types
of incidents [Parkes 2003], while a German-based study of aggressive behaviour
against the self and others among first admission patients with schizophrenia revealed
that 5% of patients were mechanically restrained [Steinert et al. 1999]. Another US-
based study reported that patients tried to resist transfer, had to be 'forcibly subdued',
or that a 'violent struggle ensued' between patient and officers in 40% of cases within
a maximum-security hospital [Dietz and Rada 1982]. Furthermore, a 1 year study of
40 hospital wards in the USA and Canada revealed that about two thirds of the all
incidents led to seclusion or mechanical restraint [Reid et al. 1989]. Finally, a
Swedish study that analysed 3 years of data within one Swedish-based acute
psychiatric ward revealed that in 46% of 137 aggressive/violent cases, the patient had
to be give compulsory intra-muscular medication or be immobilised [Omerov et al.
2002]
Other containment responses including staff contacting the police which a UK-based
study of 37 physical assaults in a psychiatric unit over a 12 month period reported
[Edwards et al. 1988]. The latter was the only study to have reported that the
assailant was denied some of their privileges (this occurred for 2 out of 25
assaultive patients). The use of constant special observation was reported by only
one study which reported that violent patients were more likely to have been under
constant special observation the month prior to the patients becoming violent [Tardiff
1983]. Staff locking the ward doors was reported by a US-based study of a staff
murder that occurred within a State psychiatric hospital [Turns and Gruenberg 1973].
Only one study reported that the being detained as a consequence of violence
specifically that violent patients were found to be significantly more likely than non-
violent patients to be detained in hospital than non-violent patients (58.5% vs. 22.4%
respectively; OR=4.87, CI=2.75-8.66) [Benjaminsen et al. 1996], while a UK-based
study of violence in an inpatient acute psychiatric unit reported the outcome of staff
confronting the assailants specifically that nurses were more willing to confront
violent female patients on their own without colleague support, compared to violent
male patients. Finally, an Australian-based study of aggression within acute
psychiatric settings reported that an assailants nursing management plan was
reviewed after 26% of violent incidents.
Patient transferred or discharged
Seven studies (6.5%) reported this type of outcome which consisted of 5 lower-level
themes including violent/aggressive patients being transferred to a higher security
ward including a US-based study of repeated assaults within a Veterans inpatients
unit which found that measures such as this and transfer to jail were used in 4.7 % of
422 assaults [Blow et al. 1999]. Being transferred to another hospital was a
consequence of violence/aggression reported by four studies: one which reported this
outcome for 31% of incidents (total incident N not reported) within Australian-based
acute psychiatric settings [Delaney et al. 2001], and another an Australian-based study
of violent incidents within inpatient psychiatric settings which reported that non-
recidivist patients were more likely to be transferred to another hospital after
becoming violent [Owen et al. 1998]. Additionally, a study of 40 hospital wards in the
USA and Canada revealed that assailants who committed the most severe incidents
slightly more likely than other assailants to be transferred to another hospital or be
discharged [Reid et al. 1989], while another study reported being transferred to
another hospital in 10.7% of 2180 incidents within a UK-based medium secure unit
[Gudjonsson et al. 2000]. The latter study also reported that in 0.02% (n=49) of 2180
incidents, the assailant was transferred to a psychiatric intensive care unit, while a
one year study of a UK-based general psychiatric hospital also cited this theme [Tobin
et al. 1991]. A German-based study of aggressive behaviour among first admission
patients with schizophrenia at a general psychiatric hospital which reported that 17%
of male assailants and 3% of female assailants were prosecuted for their aggressive
behaviour during their admission [Steinert et al. 1999]
Victim psychological outcome
A total of 12 studies (11.1%) reported 16 types of psychological outcomes for the

victim of a violent/aggressive incident. This included irritability which was reported
to be one of the most commonly reported symptoms immediately following an assault
on staff at a UK-based acute psychiatric inpatient unit [Whittington and Wykes 1991].
The latter study, which prospectively interviewed staff victims following a violent
assault also reported muscle tenseness, anxiety, intrusive thoughts, and the staff
ruminating about the incident as commonly reported symptoms. An earlier study by
the same authors also reported muscle tenseness, intrusive thoughts and rumination
about the incident [Whittington and Wykes 1989].
A UK-based study of assaults on staff in a locked inpatient acute psychiatric ward

revealed that in 47% of 41 recorded staff assaults over a 6 month period, the staff
victim felt a change in attitude toward the assailant - in particular anger at the patient
for being 'allowed to get away with' their violent behaviour, changing to resentment
and subsequently fear of patient [Aiken 1984]. This study also reported that two
other victims felt that their job satisfaction had decreased because of the violence.
One other study also reported staff anger towards the assailant as an outcome a US-
based study that preliminarily evaluated the data collected during ASAPs first 90
days [Flannery et al. 1991]. The latter study also reported that the staff victims sleep
disturbances about the incident, an outcome which was also reported by another US-
based study that examined various characteristics related to assault over a 3 and a half
month period in one large neuropsychiatric hospital [Lanza 1988], as well as a UK-
based prospective study of verbal aggression towards psychiatric staff who reported
that 43% of 68 staff victims dreamt about the incident [Adams and Whittington 1995].
The latter study also reported that 78% of the victims tried to repress the incident As
well as the aforementioned Whittington and Wykes (1991) study, three other studies
reported staff anxiety as an outcome of violence/aggression. An the study by the
same authors [Whittington and Wykes 1989], as well as the Adams and Whittington
(1995) study which asked staff victims to estimate their level of anxiety at the time of
the incident using a 5-point Likert-type scale (0 = no anxiety to 5 = extreme anxiety).
They revealed that the mean level of staff anxiety for inpatient staff was 1.75, while
female staff reported higher levels of anxiety (2.26) than males (1.54), while anxiety
was reportedly higher during threatening incidents (2.27) than during incidents
involving purely verbal abuse (1.71) (although these figures include community
psychiatric nurses whose mean anxiety scores were higher than inpatient staff).
Another study examined aggression among psychiatric inpatients in Australian
rehabilitation wards and found that 35.2% of 806 incidents resulted staff feeling
shaken up [Cheung et al. 1996].
Another study which retrospectively examined ASAP data reported victims symptoms
associated with acute stress disorder and post-traumatic stress disorder (PTSD)
[Flannery and Walker 2001], while three other studies by the same lead author also
reported the latter psychological outcome via retrospectively analysing ASAP data
specifically, that more female staff victims compared to male staff victims of severe
threats experience PTSD-related symptoms at the time of the incident [Flannery, Jr. et
al. 1995], that psychological trauma symptoms of physical, intrusive, and avoidant
responses were frequently associated with staff assaults [Flannery, Jr. and Walker
2008], and that 53% of staff victims had physical arousal symptoms associated with
their assault [Flannery et al. 2006]. A UK-based prospective study of verbal
aggression towards psychiatric staff reported that 93% of 14 staff victims who
completed the Revised Impact of Events Scale experienced PTSD symptoms
[Adams and Whittington 1995].
Experiencing disruptions in mastery, attachment, and meaning were three other

psychological outcomes all of which were reported by various Flannery studies.
Flannery defines mastery as one's ability to reasonably shape one's environment,
attachments as the caring and support of others, and meaning as the ability to make
understandable sense out of what has happened. One study reported that disruptions
of these domains were frequently recorded across all categories of assault reported via
ASAP [Flannery and Walker 2001], while another study reported that more female
staff victims compared to male staff victims of severe threats experience disruptions
in the sense of mastery and meaning of the event at the time of the incident as well as
one day later, and that these disruptions could potentially occur up to 10 days after the
incident [Flannery, Jr. et al. 1995]. An earlier study that preliminarily evaluated
ASAP found that 69% of staff victims regained a sense of mastery within 3-10 days
of the incident [Flannery et al. 1991]. A 15 year analysis of ASAP data revealed that
disruptions of reasonable mastery, caring attachments, and purposeful meaning
frequently associated with all categories of assault, although physical and sexual
assaults, and verbal threats resulted in more frequent domain disruptions than
nonverbal intimidation incidents [Flannery, Jr. and Walker 2008]. Additionally,
69.4% of assaulted staff were reported to frequently experience disruptions in their
sense of mastery of the environment, 58.4% of staff victims experienced disruptions
in their ability to understand or make meaningful sense of the incident [Flannery et al.
2006].
Victim behavioural outcome
A total of 6 studies (5.6%) reported 9 different types of behavioural outcomes for the
victim of a violent/aggressive incident. This included staff fatigue which was cited as
an outcome by a UK-based exploratory study of coping strategies used by staff in an
acute psychiatric inpatient unit soon after a patient assault [Whittington and Wykes
1991]. The latter study and an earlier 6 month study of acute inpatient staff injuries
also reported that staff used alcohol, smoked, and increased appetite in the hours
and first few days after an incident [Whittington and Wykes 1989]. An increase in
appetite and strained family relationships were outcomes reported by a US-based
study that examined various characteristics related to assault over a 3 and a half
month period in one large neuropsychiatric hospital [Lanza 1988]. Another type of
behavioural outcome was resigning from their post which was cited by two studies
one which investigated staff assaults over a 6 month period in a UK-based locked
acute psychiatric ward [Aiken 1984], and a study that preliminarily evaluated
ASAPS first 90 days which found that one employee left the their job as a result of
being assaulted [Flannery et al. 1991]. A US-based study that prospectively studied
violence and social structure on four acute and two chronic wards reported that in
contrast to the more peaceful wards, on violent wards there was usually no post-
incident debriefing/review [Katz and Kirkland 1990]. Finally, a study that evaluated
90 days worth of ASAP data reported that, from 67 recorded staff assaults, 1 staff
member was referred for counselling, while 7 staff victims attended support group
meetings [Flannery et al. 1991].
Property / objects damage
Fourteen studies (13%) reported damage to property/objects as an outcome of

inpatient violence/aggression, 13 of which reported the number of total incidents as
well as the number of incidents which resulted in property/objects damage, whereas
one study did not [Ketelsen et al. 2007].
The highest rates of property/object damage were found to be 35% of 17 incidents

over a 2 month period in a UK-based forensic hospital [Carton and et al. 2003], 26%
of 323 incidents over a 5 year period in an Italian-based acute inpatient unit [Grassi et
al. 2001], 20% of 197 incidents over a 1 year period in an Australian forensic
psychiatric hospital [Daffern et al. 2003], and 20% of 164 incidents over a 24 week
period in a Dutch acute psychiatric admissions ward [Nijman et al. 1997]. The next
highest rate was found to be 16% of 135 incidents over a 2 year period within a UK-
based forensic unit [Agarwal and Roberts 1996], followed by 12% of 419 incidents
over a 5 month period in a large US-based state psychiatric hospital [Kraus and
Sheitman 2004], and 11% of 820 incidents over a 3 year period in a UK-based
medium secure unit [Torpy and Hall 1993]. Lower rates included 9% of 316 incidents
over a 6 month period on 3 Australian-based forensic wards [Daffern et al. 2006], 9%
of 1289 incidents over a 3 month period in 2 units located in an Australian primary
psychiatric hospital and a 6 month period in 3 acute psychiatric units of an Australian
general hospital [Owen et al. 1998], and 6% of 119 incidents over a 25 week period
within one Swedish psychiatric intensive care unit [Palmstierna et al. 1991]. The
lowest rates of property/object damage were 4% of 331 incidents over a 6 month
period in an Australian forensic psychiatric hospital [Daffern et al. 2003], 2% of 264
incidents over a 10 month period in 5 UK-based acute wards [Foster et al. 2007], and
1% of 806 incidents over an 8 week period within Australian rehabilitation wards
[Cheung et al. 1996].
Using the total number of property/damage episodes as well as the total number of
violent/aggressive incidents reported in the above thirteen studies, the percentage of
incidents resulting in property/objects damage was calculated. Across all studies
which reported this theme, (as well as the total number of violent/aggressive
incidents), the mean percentage of this rate was found to be 13.12% (SD = 9.9) (see
table 9). When settings were compared, there was a slightly higher rate within
forensic settings, while a substantially higher rate was found within UK-based studies
compared to Australian-based studies. There were no meaningful differences between
data sources.
Table 9: Rates of property/objects damage

Percentage of
property/objects
Mean (SD)
damage controlling for
Mean (SD) Incidents property/object
Grouping variable incidents (oral
[n studies] damage episodes [n
medication N /
studies]*
Incident N * 100) [n
studies]*
All studies 521 (583) [61] 39 (36) [13] 13% (10) [13]
Country: UK 501 (549) [19] 31 (40) [4] 16% (14) [4]
* = only studies which reported property/object damage were included in calculation
No consequence
Nine studies (8.3%) reported that the number of incidents which resulted in no
consequences for patients or staff. This included 57% of 477 incidents over an eight
week period within 11 Australian-based psychiatric rehabilitation wards in which
there were no consequences for the victim, and 12.4% of incidents in which no
containment measure was used by staff [Cheung et al. 1997]. Additionally, 56% of
806 incidents over an 8 week period within Australian rehabilitation ward and 10% of
incidents in which no containment measure was used by staff [Cheung et al. 1996].
Furthermore, 44% of 323 incidents over a 5 year period in an Italian-based acute
inpatient unit in which there were no immediate consequences [Grassi et al. 2001],
and 22% of 264 incidents over a 10 month period in 5 UK-based acute wards in which
there were no consequences for the victim, and 1 incident in which no containment
measure was used by staff [Foster et al. 2007]. Fifteen percent of 164 incidents over a
24 week period in a Dutch-based acute psychiatric admissions ward resulted in no
containment measure being used [Nijman et al. 1997], while 5% of 409 incidents over
a 7 year period within one Italian 15-bed acute inpatient unit in which no containment
measures were used [Grassi et al. 2006]. Other rates included 3% of 1144 incidents
over a 6 month period at a UK-based forensic hospital in which no containment
measure was applied [Larkin et al. 1988], and 2% of 130 incidents over a 5 month
period within a large NHS psychiatric hospital in which no consequence occurred
because the incident was not witnessed by staff [Shepherd and Lavender 1999].
Finally, 2% of 507 incidents over a 7 year period resulted in no containment measure
being used within two Norwegian acute psychiatric inpatient wards [Langsrud et al.
2007].
The findings of this review lend some indirect support of the City model. Direct
support is minimal given that this review is examining the outcomes of violence and
aggression, rather than the contributing factors.
One source of indirect support for the City model comes from the containment/staff
response findings. Specifically, these findings emphasise the importance of technical
mastery and teamwork skill two components of the model which play crucial a role
in determining how effective staff are in delivering containment to violence. As the
results of the antecedents review highlight, containment procedures such as restraint,
seclusion, medication administration and verbal de-escalation may trigger more
conflict when carried out poorly, and which have been clearly documented in this
review to be highly frequently used in response to violence and aggression.
The emotional regulation component is also indirectly supported by this review. This
is because a number of studies and lower-level themes related to the psychological
and behavioural outcomes of the victim, all of which were negative. Therefore, it can
be argued that if staff become victims of an aggressive/violence incident, their ability
to effectively regulate their emotional state during future interactions with patients
may become compromised. For example, if a nurse who has recently been assaulted
by a particular patient becomes angry and/or holds resentment toward the assailant
(and potentially other patients), he/she may not carry be not keep their emotional state
regulated and work as effective as possible. A staff victim who is suffering from such
negative outcomes may also struggle to attain positive moral commitments, engage in
effective team-working, and may have their psychiatric philosophy impaired
temporarily or even permanently.
One of the underlying assumptions of the City model is the way staff can directly
influence the likelihood of conflict and containment levels, particularly through the
way that they interact with their patients. This is potentially supported by the finding
that that there are higher rates of seclusion and oral medication use in acute wards
compared to forensic wards. These differences may be due to the inherent differences
within the patient population, or they may reflect the differences in working style and
practice across the two types of settings. If the latter is at least partially true, this
would lend some support to the assumption that differences in staff are a key
contributor to differences in conflict and containment rates.

One of the main focuses of this review is upon the nature and severity of the physical
injuries which inpatient staff (and patients) experience as a result of violence and
aggression. The impact of the physical injuries is an area which is not explicitly
referred to within the City model. For example, if a key member of staff is not able to
work for an extended period of time due to a serious physical injury, there may be
repercussions on how the ward is run in general as well as the psychological
implications upon the rest of the team which may impact the staffs ability to
positively appreciate (if morale becomes poor), as well as the teams ability to work
effectively together.
The impact of property and object damage is also not referred to within the City
model. This may be because no consideration to the physical environment is explicitly
referred to within the City model. If it is considered that a high-quality, functional
physical environmental is an important component of a therapeutic and safe
psychiatric ward (a theory which is supported by our transitions analysis and the
antecedents review), then it is logical to assume that damage to properties and objects
may produce an overall negative effect. It is also possible that staff and patients attach
some psychological significance to certain personal objects which may upset them
and trigger conflict (and containment) if they are damaged or destroyed.
As stated earlier, this review highlighted some important differences in certain

containment measures, as well as the rate and severity of physical injuries, within
different inpatient settings. This has two possible implications. Firstly, if the
likelihood of certain containment measures is setting-specific, then some
consideration of setting type should be included in the City model. Secondly, if we
deduce from the findings that acute wards are more dangerous than forensic wards
(due to the comparatively higher injury rates and lower numbers of mild injuries),
then one potential explanation for the difference could be the predictability level of
the patients behaviour. This is a reasonable assumption as the level of patient
throughput is much higher within acute settings, and therefore staff have much less
time to interact and learn about the patient including what his/her particular conflict
triggers are, and how and when best to carry out containment measures. Therefore, the
level of patient predictability may be an important addition to the City model.
5.4 Discussion
Similarly to the antecedents review, one of the most discernable findings of this
review is that the potential consequences and outcomes of inpatient
violence/aggression are wide-ranging. This is underlined by the fact that there 8
higher-level themes incorporating a total of 67 distinct lower-level themes across the
108 studies in this review. The consequences ranged from the nature and severity of
physical injuries, patient transfers/discharges, psychological and behavioural
outcomes for the victims, and damage to property/objects. Another distinguishing
finding is that a large proportion of the papers include data on the prospective/live
consequences and outcomes that ensued immediately after the incident
(approximately a quarter all of papers across the entire literature review included such
information). More papers provided live consequences data than antecedents data,
perhaps suggesting that studies are either slightly more interested in what happens to
the patient/staff following the incident than what led to the incident, or that staff are
focused more on documenting the consequence of an incident than the triggers of it.
Another similarity to the antecedents review is that the types and rates of
consequences and outcomes represented in this review are staff-based depictions of
reality. It is the psychiatric staff members who interpret their personal view of the
incident and subsequently complete an incident form, a SOAS/R, a study
questionnaire, a claim form, an assault form, and/or who are qualitatively interviewed.
One hundred and three studies (95.3%) of the 108 studies reported consequences data
exclusively from the staffs perspective, while only one study captured the patient
perspective. Such a large disparity of perspectives also implies that the true breadth
and scope of the consequences and outcomes of violence and aggression remains
uncertain. In order to bridge this gap, future studies interested in the consequences
and outcomes of inpatient conflict should also use video camera footage as well as the
patient interviews and questionnaires. The former method would be a useful objective
tool for recording containment responses; however the latter methods would be the
only mechanisms towards understanding the psychological consequences of the
patient. It may also be useful to understand the wider consequences of inpatient
conflict events such as violence and aggression by researching the consequences for
the patient and staff witnesses as well as the patient and staff communities as a whole.
Such research is necessary in reducing the perspective disparity and augmenting our
understanding of what the consequences and outcomes of violence and aggression are,
and what the resulting effects of such phenomena are. It may also be useful for staff to
record in their incident forms the psychological consequences for the victims and
assailants soon after the event, particularly if the process helps staff become more
psychologically understanding of their patients and colleagues. Talking to the victims
and assailants about how they are feeling soon after the incident will also show
support and empathy for both the patient and staff communities.
The most frequently reported type of consequence across all of the violence and
aggression literature pertained to physical injuries. This predominantly regarded the
types of injuries experienced by the staff victims of the assault. An extensive range of
injury types and severity were cited implying that victims of assaults could experience
any type of injury. Due to the lack of data necessary in calculating rates, it was not
possible to accurately assess which types of injuries are most likely to occur during an
incident. However, if the number of study citations of types of injuries is to be used as
an indicator, then the most frequent type of injury may be head injuries which were
referred to by 28 studies by far the largest number of studies which specified an
injury type. The next most frequent study citations were nine studies which reported
scratches/cuts/nosebleeds/grazes, eight studies which reported injuries to the
back/spine/trunk, six which reported a bone injury and 6 which reported a serious
open wound or laceration. It is reasonable to expect that head injuries could be the
most common type of injury experienced after an assault as it would be expected that
punches to the face/head area would be a common method of assault. As head injuries
can be potentially severe and traumatic, the obvious implication is that staff are
trained in defending their heads effectively during an assault so that the risk of
experiencing an injury is minimised.
There was, however, enough data to calculate the mean rate of physical injuries
controlling for total violent incidents. This was found to be 37% which can be
interpreted to purport that for every three violent/aggressive incidents that a staff
member is involved in, they are likely to be injured at least once. There are important
clinical implications associated with this finding. Firstly, there is a clear need for staff
to be well trained in how to non-harmful defensive techniques so that they can
minimise their risk of injury during an assault. Secondly, it could be argued that a
37% injury rate is too high and that more could be done to de-escalate the patient and
prevent the assault from occurring. Thirdly, if a staff member is injured, first aid
should be delivered as quickly and as effectively as possible so that the risk of the
injury becoming worse is reduced and that the amount of recovery time that an injured
staff member might need is minimised. This can be ensured if (a) wards regularly
check to make sure that first aid boxes are always available and fully kitted and if (b)
staff and patients take part in regular first aid training sessions so that anyone on the
ward can be potentially be on hand to provide first aid to the victim. If this can be
achieved, the morale of the entire ward community should be boosted.
Another meaningful finding was the contrasting rates of injury by setting

specifically that staff involved in a violent/aggressive incident within acute settings
are 20% more likely to be injured as a consequence compared to forensic settings.
This implies that acute wards are more dangerous for psychiatric staff (and patients)
than forensic wards. This raises a number of questions: Could it be that forensic wards
are better prepared to deal with a violent incident than on an acute ward, perhaps due
to better training in injury prevention and/or dealing with violent events? Perhaps
they have higher levels of staffing which minimises the risk an individual nurse?
Perhaps they have better management strategies? Another potential explanation for
the difference could be the predictability level of the patients behaviour. This is a
reasonable assumption as the level of patient throughput is much higher within acute
settings, and therefore staff have much less time to interact and learn about the patient
including what his/her particular conflict triggers are, and how and when best to carry
out containment measures. The argument for acute wards being more dangerous for
staff than forensic wards is further corroborated when injury severity rates are
considered. This is because injuries were more likely to be considered severe within
acute settings compared to forensic settings (although only three forensic-based
studies reported the required data) both when controlling for total violent/aggressive
incidents and total number of physical injuries. Non-UK, USA or Australia-based
studies produced substantially higher rates of severe injuries which tentatively
suggests that psychiatric wards from these countries pose a comparatively greater
danger to psychiatric staff.
The second most frequently reported higher-level consequence theme was

containment/staff response. A total of fifty-four studies cited 15 types of containment
measures/staff responses to violent/aggressive incidents which is a considerable
number and emphasises the possible range of measures at the staffs disposal when
facing aggression/violence and other conflicts. Despite the breadth of reported
containment types, no studies in the review cited the use of intermittent observation
which is considered surprising given that this measure has been previously
documented to be one of the most frequently used within UK inpatient acute wards
[Bowers 2009] and that it associates with reduced self-harm rates which may occur
during patient violence/aggression [Bowers et al. 2008]. The most frequently cited
containment measure was seclusion, which was cited by nineteen studies, followed by
oral medication (27 studies), mechanical (19) and manual (18) restraint, time
out/removed from the situation (16), intra-muscular medication (14) and verbal de-
escalation. However, the overall most frequently used containment measure in terms
of rates was found to be manual restraint (34%), followed by verbal de-escalation
(30%), oral medication (24%), seclusion (21%), time out (18%) and intra-muscular
medication (18%). However, it is important to take into account that these are
estimates based upon available data, and that it is possible that other containment
measures for which a reliable rate could not calculated (due to low numbers of studies
providing the necessary data) may be used as frequently.
Seclusion, oral medication and manual restraint were the only containment measures
which were able to be analysed and meaningfully compared across settings. These
comparisons revealed that each of these measures were employed to a substantially
greater degree within acute settings than forensic settings during or following
violence/aggression. This adds evidence to the theory that acute psychiatric wards are
less calm and safe places of recovery than forensic settings. There are a number of
possible explanations for this difference. Firstly, nurses working with acute settings
may be more reliant of such containment measures because they are not confident or
effective as forensic nurses at verbally de-escalating a violent/aggressive patient.
Another possibility is that there may be more conflict within acute wards in general.
As conflict and containment have been showed to be correlated within acute
psychiatric settings [Bowers 2009], this would logically result in the higher use of
containment measures. Another potential explanation for the difference could be that
forensic staff are better at predicting what might trigger a patient to become
violent/aggressive than acute nurses due to a greater familiarity of their patients and
therefore containment measures are not as necessary. The use of seclusion within
inpatient psychiatric services was also found to be greater within the UK and USA
compared to Australia for containing with violence/aggression. This supports the
findings of a previous study which reviewed international seclusion rates within
inpatient psychiatry also revealed that seclusion rates are lower within Australia (and
New Zealand) than in the USA and UK [Janssen et al. 2008].
A methodological problem that surfaced during the thematic analysis was that most
non-UK literature did not explicitly make a distinction between manual and
mechanical restraint and instead only referred to physical restraint. This problem
was addressed by making informed decisions on which type of restraint the study
authors were most likely to be referring to, given the country in which the study took
place and other implicit references to the type of restraint being measured. It is
therefore clear that future studies must clearly state which type of restraint is being
researched and that clear definitions provided, so that interpretations of such results
are accurate and applied correctly.
Twelve studies referred to the psychological outcome of the victim of violence and
aggression, while only 6 referred to behavioural outcome of the victim. The reason
why so few studies referred to such outcomes is because it often takes time for such
outcomes to become apparent. This review examined live consequences data that
were collected immediately or soon after the incident which would be unlikely to
capture such outcomes. Therefore, studies which surveyed staff victims at a future
time point would be much more likely to research such outcomes. Although it was not
possible to meaningfully analyse the rates of these outcomes within this review (due
to low study numbers and available data), it is interesting to note the large range of
lower-level themes related to this outcome despite the limited number of studies
captured by this review. The latter tentatively indicates the importance of such
outcomes which may have short-term and long-term negative clinical and economical
repercussions. It is recommended that staff are provided with safe areas in which
they can express such outcomes if and when they occur so that they can be helped by
the appropriate support structures to recover more quickly and effectively.
Dissimilar to the antecedents review was that were very few studies (nine in total)
which could not identify at least one type of consequence or outcome following a
violent/aggressive incident. This is possibly because it is easier for staff to observe a
consequence of an incident, compared to an antecedent of an incident. Another
interpretation is that staff are more interested or focused in recording consequences-
type data, perhaps due to common practice and custom.
6. PROFILE OF VIOLENT AND AGGRESSIVE PATIENTS

Of the 424 empirical studies included in the literature review, 75 (18%) papers made
some sort of comparison between groups of patients as can be seen in Table 1.
Table 1: types of comparison studies

Type of Comparison N %
Aggressive vs. Non 29 38.67

aggressive Random
Aggressive vs. Non 7 9.33
aggressive Controls
Repeater/High vs. Single/Low 6 8
Repeater/High vs. Single/Low 6 8

vs. Non aggressive Random
Repeater/High vs. Single/Low 4 5.33
vs. Non aggressive Control
Other 23 30.67
Aggressive vs. Non-aggressive comparison studies
From the 29 aggressive vs. non aggressive random group studies were excluded from
the analysis if there was any missing data (Goldberg et al. 2007; Flannery et al. 1998;
Daffern et al. 2008), if it was unclear whether the aggression had occurred on the
ward when defining the groups (Abushualeh et al. 2006; Margari et al. 2005) and if
the demographic data was reported in terms of the number of aggressive incidents
rather than the number of aggressive patients (Chou et al. 2001). From the aggressive
vs. non aggressive control studies, 4 papers were excluded (Cheung et al. 1997;
Ramussen et al. 1995; Doyle et al. 2006; Lanza et al. 1988) as they were comparing
factors other than the patient demographics we were interested in. Ten papers reported
more than one comparison. Where aggressive patients were split into those who had
been physically aggressive versus verbally aggressive or aggressive against object
(McNiel et al. 1988; Raja et al. 1997; Raja et al. 2005) the data was combined to
produce one aggressive group for comparison. This was also the procedure for studies
that compared persistently and transiently aggressive patient over the study period
(Krakowski et al. 1989a; Krakowski et al. 1997). Some studies made further
comparisons using a subset of patients from either the aggressive group (Barlow et al.
2000; Daffern et al. 2005) or the non aggressive group (Ketelsen et al. 2007). These
extra comparisons were not included in the analysis. Two studies were excluded from
the analysis (Krakowski et al. 1989b; Krakowski et al. 1999) as the non-aggressive
group was matched to the aggressive group.
A total of 34 studies (See Table 2) remained and were analysed in the present series of
meta-analyses. Where available the following information was collected from each
paper: patient demographics (for gender, ethnicity, marital status, diagnosis, history of
violence, suicide, drug abuse and admission type this was split into binary data, e.g.
the proportions of patients in the aggressive and nonaggressive group that were male
or female; for age and years of education continuous data was collected, e.g. means
and standard deviations for each group), size of sample, type of ward, violence
definition (verbal, physical against others, physical against objects, physical against
self), and country.
Data analysis
A series of meta-analyses were performed on each demographic factor to estimate the

common effect over several studies using STATA. For binary data the effect measure
was the ratio of proportions of aggressive and non aggressive patients were
calculated. For continuous data the observed differences in means between the two
groups was calculated.
Author Country Setting Data Status Number Violence Measurement Duration Type of sample
Definition
Barlow et al. 2000 Australia Acute Gender, Diagnosis, agg/nonagg 174/1096 VPOS SIR 18 Random
No. previous months
admission
Blomhoff et al. Norway Acute Gender, Age, History agg/nonagg 25/34 P SIR 12 Random
1990 of C & C months
Coldwell et al. UK Forensic Age agg/nonagg 31/20 PO Patient notes 12 Random
1989 months
Daffern et al. 2005 Australia Forensic Age, Gender, agg/nonagg 105/127 VPO OAS 12 Random
Diagnosis months
Dietz et al. 1982 USA Forensic Age, Ethnicity, Years agg/nonagg 64/147 P lead to SIR 12 Random
of education seclusion months
Dolan et al. 2008 UK Forensic Age, Gender, agg/nonagg 79/68 VP SIR Missing Random
Ethnicity, Marital
status, Diagnosis
Doyle et al. 2002 UK Forensic Age, Gender, agg/nonagg 45/52 VP VRAG 3 months Random
Ethnicity, Marital
status, Diagnosis
Edwards et al. UK Mixed Marital status, agg/nonagg 25/25 P Interviews 12 Matched for Age
1988 Diagnosis, Admission months and Gender
type, History of C & C
Fullam et al. 2008 UK Forensic Age, Yrs in education, agg/nonagg 33/49 PO had to SIR Missing Men/schizophrenics
medication be
instigated
Grassi et al. 2001 Italy Acute Age, Gender, Marital agg/nonagg 116/1418 VPO SOAS 60 Random
status, Diagnosis months
Harris et al. 1983 USA Forensic Age, Yrs in education, agg/nonagg 45/45 P SIR 60 Random
Diagnosis, No. months
previous admissions
Hillbrand et al. USA Forensic Age, History of C & C agg/nonagg 79/79 P lead to Patient notes 36 Random
1996 injury months
Hoptman et al. USA Forensic Age, Ethnicity, Yrs. in agg/nonagg 60/123 P NOSIE 3 months Men
1999 education
James et al. 1990 UK Acute Age, Gender, agg/nonagg 64/216 POS SIR 15 Random
Ethnicity, Diagnosis, months
Admission type
Karson et al. 1987 USA Research Age, Gender, agg/nonagg 45/95 P Patient notes 135 Aggressive group
Diagnosis, No. months had not responded
previous admissions, well to neuroleptic
History of C & C treatment
Kennedy et al. UK Forensic Gender, Ethnicity, agg/nonagg 27/54 PO 10+ SIRS 4 years Random
1995 Diagnosis, History of incidents
C&C
Ketelsen et al. Germany Mixed Age, Gender, Marital agg/nonagg 171/2039 VPO SOAS 12 Random
2007 status, Diagnosis, months
Admission type, No.
previous admission
Krakowski et al. USA Mixed Diagnosis & History of agg/nonagg 77/40 VPO Patient notes 2 months Matched for age,
1989a C&C sex, race and
chronicity of illness
Krakowski et al. USA Mixed History of C & C, agg/nonagg 75/62 P MOAS and 26 Matched for Age,
1997 Admission type Patient notes months Gender, Ethnicity,
Diagnosis, Length
of stay
Lam et al. 2000 USA Acute Age, Gender, agg/nonagg 76/314 P lead to SIR 129 Random
Ethnicity, Diagnosis, injury months
Admission type,
History of C & C
Lanza et al. 1994 USA Veteran Ethnicity, Marital agg/nonagg 36/36 VP Patient notes Matched for Age
hospital Status, Diagnosis and Gender
McKenzie et al. UK Forensic Age, Gender agg/nonagg 70/24 PO SIR 2 weeks Random
2005
McNiel et al. 1988 USA Acute Age, Gender, agg/nonagg 138/100 VPO Patient notes 3 days Involuntary patients
Ethnicity, Marital
status, Diagnosis,
History of C & C
Mellesdal et al. Norway Acute Age, Gender, agg/nonagg 98/836 VP REFA 36 Some day patients,
2003 Diagnosis, Admission months numbers not
type specified
Nijman et al. 1997 Netherlands Acute Age, Gender, agg/nonagg 31/31 VPO SOAS 6 months Random
Diagnosis, Admission
type
Nijman et al. 2002 Netherlands Acute Age, Gender, agg/nonagg 31/58 VPOS SOAS 9 months Random
Diagnosis, Admission
type
Noble et al. 1989 UK Mixed Ethnicity, Marital agg/nonagg 137/137 P Patient notes 144 Matched for Age,
status, Employment months Gender and Ward
status, Diagnosis,
Admission type, No.
of previous
admissions, History of
C&C
Oulis et al. 1996 Greece Acute Age, Gender, agg/nonagg 32/104 VPOS MOAS 5 days Random
Diagnosis
Raja et al. 2005 Italy PICU Age, Gender, Marital agg/nonagg 70/1322 P Morrison 72 Random
status, Yrs.in scale months
education, Diagnosis,
Medication,
Admission type,
History of C & C
Raja et al. 1997 Italy PICU Age, Gender agg/nonagg 22/256 P Patient notes 13.5 Random
months
Soliman et al. 2001 UK Acute Age, Gender, agg/nonagg 49/280 PO SOAS 12 Random
Diagnosis, months
Medication,
Admission type,
History of C & C
Tardiff et al. 1982 USA Chronic Age, Gender, agg/nonagg 384/4780 P NOSIE 3 months Random
Diagnosis
Troisi et al. 2003 Italy Acute Age, Admission type agg/nonagg 20/20 VPOS MOAS 6 months Men
Walker et al. 1994 UK PICU Gender, Ethnicity, agg/nonagg 16/32 P SIR 6 months Random
Diagnosis, History of
C&C
1
Abbreviations used: agg, aggressive; nonagg, non aggressive; V, verbal aggression/threat; P, physical aggression against others; O, physical
aggression against others; S, aggression against self; SIR, standard incident reports; VRAG, violence risk appraisal guide; OAS, overt aggression
scale; SOAS, staff observation aggression scale; MOAS, modified overt aggression scale; NOSIE, nurses observation scale for inpatient
evaluation; C & C, Conflict and Containment.
6.2 Results for all comparison studies
Age
From the 34 comparison studies 26 studies included information comparing the age of
aggressive and non aggressive patients. Of these half reported no significant
difference in age (Blomhoff et al. 1990; Daffern et al. 2005; Dietz et al. 1982; Dolan
et al. 2008; Doyle et al. 2002; Fullam et al. 2008; Lam et al. 2000; McKenzie et al.
2005; McNeil et al. 1988; Mellesdal et al. 2003; Nijman et al. 2002; Oulis et al. 1996;
Troisi et al 2003) whereas the other half found aggressive patients were significantly
younger than non aggressive patients (Coldwell et al. 1989; Grassi et al. 2001; Harris
et al. 1983; Hillbrand et al. 1996; Hoptman et al. 1996; James et al. 1990; Karson et
al. 1987; Ketelsen et al. 2007; Nijman et al. 1997; Raja et al. 1997; Raja et al. 2005;
Soliman et al. 2001; Tardiff et al. 1982). Eight papers were excluded from the meta-
analysis as the ages were recorded as categorical data (James et al. 1990; McNiel et al.
1988; Oulis et al. 1996; Tardiff et al. 1982), means were not reported (Blomhoff et al.
1990; Troisi et al. 2003) or because standard deviations were not reported (Dietz et al.
1982; McKenzie et al. 2005).
Figure 1 shows the difference between the mean ages of patients who had been
aggressive and those who had not been aggressive during their inpatient stay. The
findings show that the 1186 aggressive patients were significantly younger by - 0.32
years than the 7212 non aggressive patients (95% confidence intervals [CI], -0.39 to -
0.25, z = 9.30, p < 0.001). However, this result was statistically heterogeneous (Q =
34.76, p < 0.08, I2 = 51.1%). Four studies were removed from the analysis as their
samples were taken from selected groups (See Table 1: Fullam et al. 2008; Hoptman
et al. 1996; Karson et al 1987; Mellesdal et al 2003). This reduced the amount of
variability due to heterogeneity to less than 50% (I2 = 48.3) which suggests combining
the studies is valid (See Perera & Heneghan, 2008). The result remained significant;
the aggressive patients were significantly younger than the non aggressive patients
(Standard Mean Difference [SMD] = -0.33, CI = -0.41 to -0.26, z = 8.64, p < 0.001).
The meta-analysis was also run by setting to see if there were any differences between
acute and forensic wards. Aggressive patients remained significantly younger than
non aggressive patients on the 6 studies from acute wards (SMD = -0.24, CI = -0.35 to
-0.13, z = 4.13, p < 0.001) and on the 8 studies from forensic wards (SMD = -0.33, CI
= -0.46 to -0.21, z = 5.17, p < 0.001). However, the result within acute wards was
statistically heterogeneous (Q = 13.87, p < 0.05, I2 = 60.9%) but not within forensic
wards (Q = 6.07, p > 0.10, I2 = 0.00%).
Figure 1: Forest plot showing the differences in mean age between aggressive patients
and non aggressive patients2
Gender
Twenty-two studies included information comparing the gender of aggressive and non
aggressive patients. Twenty-one of these reported no significant difference in the
gender of aggressive to non aggressive patients (Barlow et al. 2000; Blomhoff et al.
1990; Daffern et al. 2005; Dolan et al. 2008; Doyle et al. 2002; Grassi et al. 2001;
James et al. 1990; Karson et al. 1987; Kennedy et al. 1995; Ketelsen wt al. 2007; Lam
et al. 2000; McKenzie et al. 2005; Mellesdal et al. 2003; Nijman et al. 1997; Nijman
et al. 2002; Oulis et al. 1996; Raja et al. 1997; Raja et al. 2005; Soliman et al. 2001;
Tardiff et al. 1982; Walker et al. 1994). McNiel et al. (1988) reported that men were
significantly overrepresented in the group of pts exhibiting fear-inducing behaviour
(verbal attacks on persons, threats to attack persons, and attacks on objects), whereas
women were significantly overrepresented in the physically assaultive group.
Blomhoff et al. 1990 was excluded from the meta-analysis as data were missing.
2
The black circle and horizontal line correspond to the standard mean difference
(smd) between groups and 95% confidence intervals. The area around the black circle
reflects the weight each study contributes in the meta-analysis.
Figure 2: Relative risk of male patients being in the aggressive group compared to the
non aggressive group
Figure 2 shows the combined relative risk that a male patient will be in the aggressive
group compared to the nonaggressive group. The findings show that there is an effect
that males have a higher probability of being in the aggressive group compared to the
non aggressive group (Combined RR = 1.10, 95% CIs = 1.03 to 1.17, z = 2.88, p <
0.01). The amount of variability due to heterogeneity was less than 50% (I2 = 48.00%,
Q = 38.48, p > 0.05).
The meta-analysis was also run by setting to see if there were any differences between
acute and forensic wards. Within acute wards (Barlow et al. 2000; Grassi et al. 2001;
James et al. 1990; Lam et al. 2000; McNiel et al. 1988; Mellesdal et al. 2003; Nijman
et al. 1997, 2002; Oulis et al. 1996; Soliman et al. 2001; Tardiff et al. 2003) male
patients were more likely to be in the aggressive group than the non aggressive group
(Combined RR = 1.14, 95% CIs = 1.03 to 1.27, z = 2.55, p < 0.01, test for
heterogeneity: I2 = 48.00%, Q = 38.48, p > 0.05). However, the opposite was found
within forensic wards (Daffern et al. 2005; Dolan et al. 2008; Doyle et al. 2002;
Kennedy et al. 1995; McKenzie et al. 2005) where male patients were more like to be
in the non aggressive group than the aggressive group (Combined RR = 0.80, 95%
CIs = 0.66 to 0.95, z = 254., p < 0.01, test for heterogeneity: I2 = 0.0%, Q = 0.78, p >
0.10).
Ethnicity
Eleven studies included information comparing the ethnicity of aggressive and non
aggressive patients. Nine of these reported no significant difference between
aggressive and non aggressive patients (Doyle et al. 2002; Hillbrand et al. 1996;
Hoptman et al. 1999; James et al. 1990; Ketelsen et al. 2007; Lam et al. 2000; McNiel
et al. 1988; Tardiff et al. 1982; Walker et al. 1994). One study (Dietz et al. 1982)
found a significant association between being nonwhite and committing an assault
whereas another study (Dolan et al. 2008) found Caucasian patients were more likely
to be aggressive than non Caucasian patients. Two studies were excluded from the
meta-analysis as data were missing (Hillbrand et al. 1996; Tardiff et al. 1982).
Ketelsen et al. (2007) and Walker et al. (1994) were also excluded as both papers
compared very specific ethnicities with all others (German nationality in the former
and afro-Caribbean in the latter).
Figure 3 shows the combined relative risk that a patient who is of an ethnic majority
(in this case Caucasian) will be in the aggressive group compared to the
nonaggressive group. The findings show no effect (Combined RR = 0.92, 95% CIs =
0.83 to 1.0., z = 1.82, p > 0.05). However, this result was statistically heterogeneous
(Q = 13.75, p < 0.05, I2 = 56.4%) suggesting that combining these studies may not be
valid. The analysis was also re-run by setting. No effect was found in both acute
(James, 1990; Lam, 2000; McNiel, 1988) and forensic (Dietz et al. 1982; Dolan et al.
2008; Doyle et al. 2002; Hoptman et al. 1999) patients.
Figure 3: Relative risk of patients of an ethnic majority being in the aggressive group
compared to the non aggressive group
Marital Status
Seven studies included information comparing the marital status of aggressive and
non aggressive patients. Two of these reported no significant difference between
aggressive and non aggressive patients (Dietz et al. 1982; Doyle et al. 2002) and one
(Dolan et al 2008) that did not report whether the differences between groups were
significant. Three studies (Grassi et al. 2001; Raja et al. 2005; Ketelsen et al. 2007)
found aggressive patients were significantly overrepresented as single compared to
non aggressive patients. McNiel et al. (1988) reported that single people were
significantly overrepresented in the group of pts exhibiting fear-inducing behaviour
(verbal attacks on persons, threats to attack persons, and attacks on objects), whereas
married patients were significantly overrepresented in the physically assaultive group.
One study was excluded from the meta-analysis as data were missing (Dietz et al.
1982).
Figure 4 shows the combined relative risk that a patient who is married will be in the
aggressive group compared to the nonaggressive group. The findings show a
significant effect (Combined RR = 0.72, 95% CIs = 0.63 to 0.83., z = 4.70, p < 0.001,
test for heterogeneity: I2 = 2.3%, Q = 5.12, p > 0.10) showing that married patients are
more likely to be in the non aggressive group than the aggressive group. The analysis
was also re-run by setting. A significant effect was found within acute and PICU
wards (Grassi et al. 2001; McNiel et al. 1988; Raja et al. 2005) but not for forensic
(Dolan et al. 2008; Doyle et al. 2002).
Figure 4: Relative risk of a married patient being in the aggressive group compared to
the non aggressive group
Years of Education
Seven studies included information comparing the number of years in education for
aggressive and non aggressive patients. Six of these reported no significant difference
between aggressive and non aggressive patients (Dietz et al. 1982; Fullam et al. 2008;
Hoptman et al. 1999; Raja et al. 2005; Raja et al. 1997; Troisi et al. 2003). One study
(Harris et al. 1983) found aggressive patients had significantly fewer years of
education than non aggressive patients. Two studies were excluded from the meta-
analysis as data were missing (Raja et al. 1997; Troisi et al. 2003).
Figure 5 shows the difference between the mean years of education of patients who
had been aggressive and those who had not been aggressive during their inpatient
stay. The findings show that there was no significant difference in the mean number
of years in education between aggressive patients and non aggressive patients
(Combined SMD = -0.13; 95% confidence intervals [CI], -0.29 to 0.03, z = 1.58, p >
0.10, test for heterogeneity: I2 = 48.9%, Q = 5.87, p > 0.10). It was not possible to
analyse this data by setting as all studies were in forensic wards apart from Raja et al.
(2005) which was set in a PICU.
Figure 5: Differences in the mean years of education between aggressive patients and
non aggressive patients
Diagnosis
Nineteen studies included information comparing the diagnoses of aggressive and non
aggressive patients. Nine of these reported no significant difference between
aggressive and non aggressive patients (Dolan et al., 2008; Doyle et al. 2002;
Hillbrand et al. 1996; Karson et al. 1987; Nijman et al. 1997; Nijman et al. 2002;
Oulis et al. 1996; Raja et al. 1997; Walker et al. 1994). Six studies found that
schizophrenia was more prevalent among the aggressive group (Barlow et al. 2000;
Grassi et al. 2001; Harris et al. 1983; Mellesdal et al. 2003; Raja et al. 2005; Ketelsen
et al. 2007). Tardiff et al. (1982) also found that nonparanoid schizophrenia was more
prevalent in the aggressive group but that a diagnosis of paranoid schizophrenia was
more likely in the non aggressive group. This study also reported that aggressive
patients were more likely to have a diagnosis of psychotic organic brain syndrome,
mental retardation or seizure disorders than non aggressive patients. McNiel et al.
(1988) reported patients with mania were more likely to be physically aggressive
whereas, Soliman et al. (2001) found a diagnosis of personality disorder predicted
violence. Diagnoses that were found to be less prevalent in the aggressive group were
bipolar and adjustment disorder (Barlow et al. 2000), depression (James et al. 1990)
and substance abuse and affective disorders (Ketelsen et al. 2007).
For the meta-analysis studies that included data about patients diagnoses were
collated into three categories: schizophrenic (including schizoaffective etc.), affective
(depression, mania etc) and other (personality disorder, organic brain syndrome etc.).
Analyses were the made comparing the ratio of affective diagnoses compared to all
other diagnoses in the aggressive and non aggressive group as well as comparing the
ratio of schizophrenic diagnoses with all other diagnoses in both groups. Five studies
were excluded from the analyses due to missing data (Hillbrand et al. 1996; Nijman et
al. 1997; Raja et al. 1997), inaccurate data (Raja et al. 2005) or because co-morbid
diagnoses were included (Soliman et al. 2001).
Affective Vs All Other Diagnoses: Four studies of the 15 had just made the
comparison between patients with schizophrenia versus all other diagnoses and so
could not be included here (Harris et al. 1993; Karson et al. 1987; Nijman et al. 2002;
Walker et al. 1994). Figure 6 shows the combined relative risk that a patient who is
diagnosed with an affective disorder will be in the aggressive group compared to the
nonaggressive group. The findings showed no significant effect (Combined RR =
0.94, 95% CIs = 0.82 to 1.08., z = 0.87, p > 0.1, test for heterogeneity: I2 = 44.1%, Q
= 17.9, p > 0.05) showing no difference in the probability that patients with and
affective disorder will be aggressive or non aggressive. The analysis was also re-run
by setting. There was also no significant effect within forensic wards or acute wards.
Figure 6: Relative risk of a patient diagnosed with an affective disorder being in the
aggressive group compared to the non aggressive group
Schizophrenia Vs All Other Diagnoses: Two studies of the 15 had just made the
comparison between patients with psychosis versus all other diagnoses and so were
not be included here (Harris et al. 1993; Nijman et al. 2002). Figure 7 shows the
combined relative risk that a patient who is diagnosed with a schizophrenia disorder
will be in the aggressive group compared to the nonaggressive group. The findings
showed a significant effect (Combined RR = 1.16, 95% CIs = 1.10 to 1.22., z = 5.52,
p < 0.001). However, this result was statistically heterogeneous (Q = 160.41, p < 0.05,
I2 = 92.5%) and remained so when some outlier studies were removed. This suggests
that in this case it may not be valid to combine these studies together. However, when
the analysis was re-run by setting the effect remained significant within acute wards
(Combined RR = 1.32, 95% CIs = 1.21 to 1.44., z = 6.16, p < 0.001) but the test for
heterogeneity was no longer significant (Q = 9.30, p > 0.1, I2 = 35.5%). No significant
effect was found (Combined RR = 1.00, 95% CIs = 0.90 to 1.11., z = 0.03, p > 0.1,
test for heterogeneity: I2 = 4.4%, Q = 1.05, p > 0.10) within the two forensic wards
(Dolan et al. 2008; Doyle et al. 2002).
Figure 7: Relative risk of a patient diagnosed with a schizophrenia disorder being in
the aggressive group compared to the non aggressive group
Type of admission
Ten studies included information comparing the type of admission (involuntary vs.
voluntary) between aggressive and non aggressive patients. Seven of these reported
that there were significantly higher numbers of aggressive patients who were admitted
involuntarily compared to non aggressive patients (James et al. 1990; Ketelsen et al.
2007; Mellesdal et al. 2003; Nijman et al. 1997; Raja et al. 2005; Troisi et al. 2003;
Soliman et al. 2001). Two studies found no significant differences between the
admission type of the two groups (Nijman et al. 2002; Walker et al. 1994) and one
study did report any type of statistic (Lam et al. 2000). Two studies were excluded
from the meta-analysis as data were missing (Nijman et al. 1997; Walker et al. 1994).
Figure 8: Relative risk of a patient who is admitted involuntarily being in the

Figure 8 shows the combined relative risk that a patient who is admitted involuntarily
will be in the aggressive group compared to the nonaggressive group. The findings
showed a significant effect (Combined RR = 2.17, 95% CIs = 2.01 to 2.34., z =
20.37, p < 0.001) that across studies involuntary patients were more likely to be in the
aggressive group. However, this result was statistically heterogeneous (Q = 475.92, p
< 0.01, I2 = 98.5%). Two studies were excluded from the analysis (Raja et al. 2005;
Ketelsen et al. 2007) so the analysis could be re-run within just acute care wards. A
significant effect was still found (Combined RR = 1.60, 95% CIs = 1.21 to 2.12., z =
3.29, p < 0.001), heterogeneity was reduced but remained significant (Q = 62.55, p <
0.01, I2 = 92%).
Number of previous admissions

Nine studies included information comparing the number of previous admissions of
aggressive and non aggressive patients. Five of these reported that aggressive patients
had significantly more previous admissions than non aggressive patients (Barlow et
al. 2000; Ketelsen et al. 2007; Mellesdal et al. 2003; Nijman et al. 1997; Nijman et al.
2002). One study (Harris et al. 1983) reported the opposite: that non aggressive
patients had significantly more previous admissions than the aggressive group and
three studies found no significant differences between the number of previous
admissions between the two groups (Hillbrand et al. 1996; Karson et al. 1987; Walker
et al. 1994). Five studies were excluded as they had missing data (Barlow et al. 2000;
Hillbrand et al. 1996; Karson et al. 1987; Mellesdal et al. 2003; Nijman et al. 1997)
and two because they reported categorical data (Nijman et al. 2002; Walker et al.
1994).
Figure 9: Differences in the mean number of previous admissions between aggressive

patients and non aggressive patients
Figure 9 shows the difference between the mean number of previous admissions
between patients who had been aggressive and those who had not been aggressive
during their inpatient stay. The findings showed a significant difference in the mean
number of previous admission between aggressive patients and non aggressive
patients (Combined SMD = 1.20; 95% confidence intervals [CI], 1.05 to 1.35, z =
15.60, p < 0.001, test for heterogeneity: I2 = 98.5%, Q = 67.09, p < 0.001).
Patient Past History of Conflict
Previous History of Violence: Six studies included information about patients

previous history of violence for both the aggressive and non aggressive groups. All of
these reported that aggressive patients were significantly more likely to have a history
of previous violence (Blomhoff et al. 1990; Karson et al. 1987; Lam et al. 2000; Oulis
et al. 1996; Soliman et al. 2001) or a significant association between violent behaviour
in the community 2 weeks before admission and aggressive patient behaviour on the
ward (McNiel et al. 1988).
Figure 10 shows the combined relative risk that a patient with a previous history of
violence will be in the aggressive group compared to the nonaggressive group. The
findings showed a significant effect (Combined RR = 2.27, 95% CIs = 1.90 to 2.69.,
z = 9.24, p < 0.001) that across studies patients with a history of violence were more
likely to be in the aggressive group. However, this result was statistically
heterogeneous (Q = 16.56, p < 0.01, I2 = 75.8%). Karson et al. (1987) was removed so
the meta analysis could be rerun on studies from acute inpatient care. The effect
remained significant (Combined RR = 2.37; 95% confidence intervals [CI], 1.97 to
2.86, z = 9.04, p < 0.001, test for heterogeneity: I2 = 80.3%, Q = 15.23, p < 0.01).
History of self-destructive behaviour (suicidal behaviour, suicidal risk, self harm,

suicide attempts): Six studies included information about patients previous history of
self-destructive behaviour for both the aggressive and non aggressive groups.
Hillbrand et al. (1996) found that aggressive patients were significantly more likely to
have a history of self-destructive behaviour than non aggressive patients. Soliman et
al. (2001) also found that aggressive patients were more likely to have a history of
self-harm but no difference between whether the patients in each group had been
admitted because of suicidal behaviour or intention. Raja et al. (2005) found suicidal
risk to be significantly higher in physically aggressive patients compared to non
aggressive patients and patients who were verbally aggressive or aggressive to
objects. Similarly Tardiff et al. (1982) reported that aggressive patients were 3/4 times
more likely to have attempted suicide than non aggressive patients. However, one
study (McNiel et al. 1988) reported that suicidal patients were less likely than non
suicidal patient to be aggressive on the ward.
Figure 10: Relative risk of a patient with a history of previous violence being in the
self-destructive behaviour will be in the aggressive group compared to the
nonaggressive group. The findings showed a significant effect (Combined RR = 1.24,
95% CIs = 1.03 to 1.50., z = 2.26, p < 0.05) that across studies patients with a history
of self destructive behaviour were more likely to be in the aggressive group. However,
this result was statistically heterogeneous (Q = 42.45, p < 0.01, I2 = 95.3%). This may
be because each study took a different measure of self destructive behaviour.
Hillbrand et al. (1996) looked at patients history of self destructive behaviour but
gave no definition for what behaviours this included. McNiel et al. (1988) measured
patients suicidal behaviour while in hospital which included any threats, gestures or
attempts. Soliman et al (1988) measured patients history of self-harm.
Figure 11: Relative risk of a patient with a history of self-destructive behaviour being
in the aggressive group compared to the non aggressive group
History of substance use: Six studies included information about patients previous
history of substance abuse for both the aggressive and non aggressive groups. Three
studies (Blomhoff et al. 1990; Soliman et al. 2001; Walker et al. 1994) reported that
aggressive patients were significantly more likely to have a history of non-alcoholic
substance abuse than non aggressive patients. Daffern et al. (2005) reported that
patients that were aggressive used a significantly higher total number of substances (0
to 5) in the years prior to assessment but that was no differences in the total number of
substances used over the lifetime of both groups. Three studies found no significant
differences in terms of the history of substance abuse between the two groups. McNiel
et al. (1988) found no significant association between substance abuse (including
alcohol) and aggression. Soliman et al. (2001) also found no significant differences in
the number of patients with a history of alcohol abuse between the two groups and
Lam et al. (2000) did not find drug or alcohol abuse to be a significant predictor of
aggressive behaviour.
Figure 12: Relative risk of a patient with a history of substance abuse being in the
substance abuse will be in the aggressive group compared to the nonaggressive group.
The findings showed a significant effect (Combined RR = 1.15, 95% CIs = 1.00 to
1.31., z = 2.02, p < 0.05) that across studies patients with a history of substance abuse
were more likely to be in the aggressive group. However, this result was statistically
heterogeneous (Q = 21.19, p < 0.01, I2 = 76.4%). Findings suggest that when alcohol
use is included there is little difference between the 2 groups, whereas the use of illicit
drugs seems to be more likely within the aggressive group. The analysis was therefore
re-run on just the studies that looked a patients history of previous illicit drug use.
The results were no longer statistically heterogeneous (Q = 2.17, p > 0.1, I2 = 7.8%)
and the significant effect remained (Combined RR = 2.09, 95% CIs = 1.46 to 3.00., z
= 4.03, p < 0.01).
History of previous arrests or convictions for violent crime: Eight studies included
information about patients criminal records in each group. Four studies found no
difference between the records of the aggressive and non aggressive groups (Dolan et
al. 2008; Doyle et al. 2002; Edwards et al. 1998; Fullam et al. 2008). Three studies
found that the aggressive group were significantly more likely to have a criminal
record (Daffern et al. 2005; Walker et al.1994) or a positive correlations between the
number of assaults and arrest for violent offences. Harris et al. (1983) reported that
aggressive patients were significantly less often admitted on criminal charges than the
non aggressive group. Four studies were excluded from the analysis because of
missing data (Daffern et al. 2005; Edwards et al. 1998; Fullam et al. 2008; Hoptman
et al. 1999).
Figure 13: Relative risk of a patient with a history of violent offenses being in the
violent convictions will be in the aggressive group compared to the
nonaggressive group. The findings showed a significant effect (Combined RR = 0.80,
95% CIs = 0.65 to 0.98., z = 2.18, p < 0.05) that across studies patients with a history
of substance abuse were less likely to be in the aggressive group. However, this result
was statistically heterogeneous (Q = 24.79, p < 0.01, I2 = 87.9%).
Employment
Three studies looked at the occupational status of both groups. Two of these found no
significant differences between aggressive and non aggressive patients (Dietz et al.
1982; Grassi et al. 2001). One study (Harries et al. 1983) found that aggressive
patients were significantly less likely to be employed.
6.3 Results for high vs. low aggression comparison studies
Inclusion criteria
From the 6 repeater/high vs. single/low aggressive group studies one was excluded
from the analysis as a large number of patients included were on outpatient wards
(Fresan et al. 2005). Ten papers reported more than one comparison. Of these half
(Barlow et al. 2000; Krakowski et al. 1989a, 1989b, 1997, 1999) made some sort of
comparison between persistently aggressive and transiently aggressive patients.
Mckenzie et al. (2005) was also included as patients within the aggressive group were
analysed further based on their number of aggressive incidents. This left a total of 11
studies (See Table 3) to be analysed in the present series of meta-analyses. Where
available the following information was collected from each paper: patient
demographics (for gender, ethnicity, marital status, diagnosis, history of violence,
suicide, drug abuse and admission type this was split into binary data, e.g. the
proportions of patients in the aggressive and nonaggressive group that were male or
female; for age and years of education continuous data was collected, e.g. means and
standard deviations for each group), size of sample, type of ward, violence definition
(verbal, physical against others, physical against objects, physical against self), and
country.
Author Country Setting Data Status Numbe Violence Measureme Duratio Type of sample
(repeaters r Definition nt n
vs. single
aggressors)
1 Barlow et al. Australia Acute Age Multiple/Singl 70/104 VPOS SIR 18 Random
2000 e months
2 Convit et al. USA Psychiatr Age, Gender, 3+ / 1-2 70/243 P SIR 6 Random
1990 ic Diagnosis months
Hospital
3 Flannery et al. USA Other Age, Gender, 3+ / 1 61/566 VPO ASAP 120 Random
2002 Diagnosis, History Sexual months
of C & C
4 Grassi et al. Italy Other Age, Gender, 2+ / 1 65/95 VPOS SOAS 84 Random
2006 Marital Status, months
Education,
Diagnosis, No of
previous
admissions, History
of C & C
5 Krakowski et al. USA Special Age, Gender, Persistent/ 38/39 VPO SIR 28 Consecutive
1989a Unit Ethnicity, Transient days admissions to
Diagnosis, History special unit
of C & C designed to
manage assaultive
behaviour
6 Krakowski et al. USA Special Age, Gender, 2+/ 0-1 28/27 VPO SIR ? Schizophrenic
1989b Unit Ethnicity, Yrs of admitted to special
educations, History unit designed to
of C & C manage assaultive
behaviour
7 Krakowski et al. USA Admissio Age, Gender, Persistent/ 34/43 P MOAS 28 Random
1997 n wards Ethnicity, Transient days
Diagnosis,
Medication,
Admission Type
8 Krakowski et al. USA Admissio Age, Gender, Persistent/ 44/52 VP MOAS 28 Schizophrenic
1999 n wards Ethnicity, Transient days
Diagnosis,
Medication, History
of C & C
9 McKenzie et al. UK Forensic Age, Gender 10+ / 1-5 17/40 PO SIR 2 Random
2005 weeks
10 Owen et al. 1998 Australia Mixed Age, Gender, 20+ / 1 20/22 VPS Morrisons 7 Random
Marital Status, month
Diagnosis,
Medication, Type of
admission,
Previous
admissions
11 Rutter et al. 2004 UK Forensic Age, Gender, 25+ / <25 17/217 Unclear SIR 192 Random
Admission type, months
Diagnosis, Ethnicity
Age
From the 11 comparison studies all included information comparing the age of repeaters and
single aggressors. Of these eight reported no significant difference in age (Barlow et al. 2000;
Flannery et al. 2002; Grassi et al. 2006; Krakowski et al. 1989a, 1989b, 1997, 1999;
McKenzie et al. 2005). Two studies found that patients who were repeatedly violent were
significantly younger than less frequently aggressive patients (Owen et al. 1998; Rutter et al.
2004). Convit et al. (1990) found that female repeaters (3+) were significantly younger than
single aggressors but there was no difference between males in either group. Five papers
were excluded from the meta-analysis as the ages were recorded as the standard deviations or
mean value were not reported (Barlow et al. 2000; Convit et al. 1990; Krakowski et al.
1989a; McKenzie et al. 2005; Rutter et al. 2004). Figure 14 shows the difference between the
mean ages of patients who had been repeatedly aggressive and those who had been less
aggressive during their inpatient stay. The findings showed no significant difference between
the two groups (SMD = -0.08, 95% confidence intervals [CI], -0.23 to 0.07, z = 1.06, p >
0.1). The result was not statistically heterogeneous (Q = 6.54, p > 0.1, I2 = 23.5%).
Figure 14: Differences in mean age between repeatedly aggressive patients and less
frequently aggressive patients
Gender
Ten of the studies included information comparing the gender of repeatedly aggressive and
less frequently aggressive patients. Eight of these reported no significant difference in the
gender of repeatedly aggressive and less aggressive patients (Flannery et al. 2002; Grassi et
al. 2006; Krakowski et al. 1989a, 1989b, 1997, 1999; McKenzie et al 2005; Owen et al.
1998). Convit et al. (1990) and Rutter et al. (2004) both found that repeatedly aggressive
patients were more likely to be females than males. Owen et al. (1998) was excluded from the
meta-analysis as data.
Figure 15 shows the combined relative risk that a male patient will be in the
repeatedly aggressive group compared to the less frequently aggressive group. The
findings show that there is an effect that males are less likely to be in the repeatedly
aggressive group (Combined RR = 0.83, 95% CIs = 0.75 to 0.93, z = 3.30, p < 0.01).
However, the test for heterogeneity was significant (I2 = 56.7%, Q = 18.46, p < 0.05).
Figure 15: Relative risk of a male being in the repeatedly aggressive group compared to the
less aggressive group
Ethnicity
Four studies included information comparing the ethnicity of repeatedly
aggressive and less frequently aggressive patients. All of these reported no significant
differences between the two groups of patients (Krakowski et al. 1989a, 1989b, 1997, 1999).
Figure 16 shows the combined relative risk that a patient who is of an ethnic majority (in this
case Caucasian) will be in the repeatedly aggressive group compared to the less frequently
aggressive group. The findings show no significant effect (Combined RR = 0.79, 95% CIs =
0.52 to 1.18, z = 1.15, p > 0.1). The result was not statistically heterogeneous (Q = 5.81, p >
0.1, I2 = 48.4%).
Figure 16: Relative risk of a patient who belongs to an ethnic majority being in the repeatedly
aggressive group compared to the less aggressive group
Marital Status
Two studies included information comparing the marital status of repeatedly aggressive and
less aggressive patients. Owen et al. (1998) found that repeatedly aggressive patients were
more likely to be widowed than less frequently aggressive patients. Grassi et al. (2006) found
no significant difference between the 2 groups (repeatedly violent group: 70.9% married; less
frequently violent group: 66.3% married). There was not enough data to run a meta-analysis.
Diagnosis
Eight studies included information comparing the diagnoses of repeatedly aggressive and less
aggressive patients. Seven of these reported no significant difference in the diagnoses of the
two groups (Convit et al. 1990; Flannery
et al, 2002; Grassi et al. 2006; Krakowski et al. 1989a, b, 1997, 1999). One study (Owen et al.
1998) reported that repeaters were more likely to suffer from organic brain syndrome or
personality disorder. For the meta-analysis studies that included data about patients
diagnoses were collated into three categories: schizophrenic (including schizoaffective etc.),
affective (depression, mania etc) and other (personality disorder, organic brain syndrome
etc.). Analyses were the made comparing the ratio of affective diagnoses compared to all
other diagnoses in the repeatedly aggressive and less aggressive group as well as comparing
the ratio of schizophrenic diagnoses with all other diagnoses in both groups. Three studies
were excluded from the analyses due to missing data (Owen et al. 1998), or because all
patients were either diagnosed with schizophrenia or schizoaffective disorder (Krakowski et
al. 1989b, 1999).
Schizophrenia Vs All Other Diagnoses: Figure 17 shows the combined relative risk that a
patient who is diagnosed with a schizophrenic disorder will be in the repeatedly aggressive
group compared to the less aggressive group. The findings showed no significant effect
(Combined RR = 1.04, 95% CIs = 0.95 to 1.14, z = 0.81, p > 0.1, test for heterogeneity: I2 =
26.3%, Q = 5.43, p > 0.10).
Affective Vs All Other Diagnoses: Figure 18 shows the combined relative risk that a patient
who is diagnosed with an affective disorder will be in the repeatedly aggressive group
compared to the less aggressive group. The findings showed no significant effect (Combined
RR = 0.70, 95% CIs = 0.43 to 1.13, z = 1.46, p > 0.1). However the test for heterogeneity
was significant (I2 = 65.5%, Q = 8.68, p < 0.05) questioning the validity of combining these
studies.
Figure 17: Relative risk of a patient with schizophrenia being in the repeatedly aggressive
group compared to the less aggressive group
Figure 18: Relative risk of a patient diagnosed with an affective disorder being in the
repeatedly aggressive group compared to the less aggressive group
Patient Past History of Conflict
Previous History of Violence: Three studies included information about patients previous
history of violence for both the repeatedly aggressive and non aggressive groups. Grassi et al.
(2006) found that repeated episodes occurred significantly more in patients with previous
violent behaviour and Owen et al. (1998) reported that repeatedly aggressive patients were
more likely to have a history of aggression (100%) compared to less aggressive patients
(26%). Flannery et al. (2002) reported no significant difference in patients history of
violence between the two groups.
Figure 18 shows the combined relative risk that a patient with a previous history of violence
will be in the repeatedly aggressive group compared to the less aggressive group. The
findings showed a significant effect (Combined RR = 1.58, 95% CIs = 1.45 to 1.73., z =
10.26, p < 0.001) that across studies patients with a history of violence were more likely to be
in the repeatedly aggressive group aggressive group. However, this result was statistically
heterogeneous (Q = 105.28, p < 0.01, I2 = 99.1%). Validity of data is questionable as only
two studies are included in the analysis.
Figure 18: Relative risk of a patient with a history of aggression being in the repeatedly
History of suicide attempts: Only one study included information about patients previous
history of suicide attempts for both the repeatedly aggressive and less aggressive groups.
Krakowski et al. (1989a) found that a history of suicide attempts was more frequent in
repeatedly aggressive patients (61.8%) than less aggressive patients (36.1%).
Previous History of a Violent Conviction: Three studies included information about patients
previous history of violent convictions for both the repeatedly aggressive and non aggressive
groups. Rutter et al. (2004) found a significant negative association between the number of
prison sentences and being repeatedly aggressive. However, Krakowski et al. (1989a, b) both
reported that a history of violent convictions was more likely in the repeatedly aggressive
group than the less aggressive group, although these differences did not reach significance.
Figure 19 shows the combined relative risk that a patient with a previous history of violent
convictions will be in the repeatedly aggressive group compared to the less aggressive group.
The findings showed no significant effect (Combined RR = 0.78, 95% CIs = 0.50 to 1.21., z
= 1.12, p > 0.1) that across studies patients with a history of violent convictions were more
likely to be in the repeatedly aggressive group aggressive group. However, this result was
statistically heterogeneous (Q = 9.8, p < 0.05, I2 = 79.6%) suggesting that the data are too few
and too different.
Figure 19: Relative risk of a patient with a history of violent convictions being in the
Previous History of Substance Use: Four studies included information about patients
previous history of substance use for both the repeatedly aggressive and less aggressive
groups. Three of these (Flannery et al. 2002; Krakowski et al. 1989b, 1999) found no
significant differences between the repeatedly aggressive and less aggressive patients.
Krakowski et al. (1989a) did find that a history of drug abuse was significantly more frequent
in repeatedly aggressive patients than the less aggressive patients group. Krakowski et al.
(1989b) was excluded from the analysis because of missing data.
Figure 20 shows the combined relative risk that a patient with a previous history of substance
use will be in the repeatedly aggressive group compared to the less aggressive group. The
findings showed a significant effect (Combined RR = 1.28, 95% CIs = 1.04 to 1.59, z = 2.30,
p < 0.05) that across studies patients with a history of drug use were more likely to be in the
repeatedly aggressive group aggressive group. The results were not statistically
heterogeneous (Q = 2.26, p > 0.1, I2 = 11.3%).
Figure 20: Relative risk of a patient with a history of substance abuse being in the repeatedly
History of arrest for violent crimes: Two studies provided information about the number of
arrests for violent crime in both the repeatedly aggressive group and the less aggressive group
(Krakowski 1989a, b). Neither of these reported significant differences between the two
groups. Figure 21 shows the combined relative risk that a patient with a previous history of
arrests for violent crimes will be in the repeatedly aggressive group compared to the less
aggressive group. The findings showed no significant effect (Combined RR = 1.04, 95% CIs
= 0.70 to 1.53, z = 0.19, p > 0.1) that across studies patients with a history of arrests for
violent crimes were more likely to be in the repeatedly aggressive group aggressive group.
The results were not statistically heterogeneous (Q = 0.08, p > 0.1, I2 = 0%).
Figure 21: Relative risk of a patient with a history of arrests for violent crime being in the
Age at first hospitalisation
Three papers included information about the ages of patients first hospitalisation for both
aggressive groups (repeaters, single aggressors). Krakowski et al. (1989a) found that
repeatedly aggressive patients were significantly younger at their first hospitalisation than
less aggressive patients (16.2 vs. 19.1). Two studies reported no significant differences in the
ages of the two groups (Grassi et al. 2006; Krakowski et al. 1989b. Krakowski et al. (1989a)
was excluded from the meta-analysis as the standard deviations were not reported.
Figure 22 shows the difference between the mean age at the first hospitalisation of patients
who had been repeatedly aggressive and those who had been less aggressive during their
inpatient stay. The findings showed no significant difference between the two groups (SMD
= -0.10, 95% confidence intervals [CI], -0.37 to 0.18, z = 0.69, p > 0.1). The result was not
statistically heterogeneous (Q = 0.16, p > 0.1, I2 = 0%).
Figure 22: Differences in mean age at the first hospitalisation between repeatedly aggressive
patients and less frequently aggressive patients
Number of Previous Admissions
Grassi et al. (2006) was the only study which compared the number of previous admissions in
each group and found episodes of violence were positively associated with the number of
previous admissions (19.68 vs. 3.42).
Other Relevant Factors

Krakowski et al (1989a,b) looked at neurological impairment within the two groups and
found that repeatedly violent patients had more neurological impairments (particularly
cerebellar signs) than the less aggressive group. This difference remained even when
neuroleptic medications were controlled for. Krakowski et al. (1997) found repeatedly
aggressive patients were more impaired in frontal lobe functioning and tended to show more
dysfunction on motor integrative tasks. Some studies also found differences between the
groups on the Brief Psychiatric Rating Scale (BPRS) and the Nurses Observation Scale
for Inpatient Evaluation (NOSIE). Repeatedly violent patients had a greater impairment on
the total BPRS score (Krakowski et al 1989a, 1999), and the Anergia (Krakowski et al
1989a), and the Hostility-suspiciousness subscales (Krakowski et al 1989a, 1999).
Differences were also found on the NOSIE mean score and NOSIE (Krakowski et al 1989a,
1999), social subscale (Krakowski et al 1989a, 1999), and routine and temper subscales
(Krakowski et al. 1999), which were both lower in the repeatedly violent group. Krakowski
et al. (1997) showed less resolution of symptoms over the 4 weeks in the repeatedly violent
patients than the less frequently violent patients.

The review of comparison studies of aggressive and non aggressive patients does not provide
much information that is relevant to the City model. To some extent although differences
between the two groups were significant, the overall effects were small suggesting that other
factors included in the City Model (staff morale, technical mastery and team working skills,
the physical environment of the ward, positive appreciation for the patients etc.) play a bigger
role in causing aggressive behaviour. This was especially apparent in the repeatedly
aggressive patients, where very few demographic factors distinguished them from less
aggressive patients. These patients are responsible for multiple episodes of aggression so it is
important to understand the triggers for this subset of patients or the variables that may be
associated with this repetitive behaviour.

Patient characteristics such as age, gender, type of admission, marital status, diagnosis, and
past history of conflict are not addressed in the existing model. Some of these factors may be
used as part of a risk assessment.
6.6 Discussion
In total, a relatively small number of comparison studies were found relative to the number of
publications on impatient aggression (17.5%). The majority of publications instead tended to
focus on the rate of aggressive incidents within wards, or the antecedents and consequences
of aggression. The small number of comparison studies suggests that future research would
benefit from focusing on this type of research design. By comparing aggressive with non-
aggressive patients important differences between the two populations may be highlighted.
These differences may help staff improve predictions of which patients might become
aggressive and enable steps to be taken to reduce an aggressive incident occurring.
All but seven of the studies included had fewer than 100 patients in both the aggressive and
non-aggressive groups and the demographics were not often the focus of the research. The
small sample sizes included in the analysis will have impacted on the result because smaller
studies were weighted as less significant. More prospective comparison studies are needed
which should be designed on the basis of power analyses to calculate the minimum sample
size required in order to detect an effect or a reliable difference between aggressive and non-
aggressive patients. Despite these limitations, a number of demographic characteristics
appear to be associated with an increased likelihood of inpatient aggression. These included
being younger, male, involuntary admissions, not being married, a diagnosis of
schizophrenia, a greater number of previous admissions, a history of violence, a history of
self-destructive behaviour and a history of substance abuse. Interestingly, a history of
previous violent convictions was associated with a decreased likelihood of inpatient
aggression. We can be fairly confident that these results represent true effects as they have
been estimated by combining the results of several studies. The effects are also more
powerful than those reported in individual studies whose findings are sometimes mixed.
The associations between demographic factors and aggression were fairly small and for some
factors (involuntary admission, number of previous admissions, history of violence, history of
self-destructive behaviour and history of previous convictions) the heterogeneity was high (I2
was greater than 50%) suggesting that combining the studies for these factors in particular
may lead to less generalisable estimates. The high levels of heterogeneity found may be
because psychiatric services can vary a great deal in terms of setting, routines, ward rules and
atmosphere. It is also probable that levels of aggression are influenced more by factors other
than patient demography. For example, these may include a patients current presentation e.g.
whether or not they appear under the influence of alcohol or drugs; the symptoms they are
currently displaying such as: fear, agitation, anger, confusion, excitement, suspiciousness or
irritability; whether patients are having delusions and/or hallucinations; and their current
attitude towards treatment and management. Contextual factors may also have a substantial
impact upon the levels of aggression, for example whether the patient has a weapon
available; the ward environment (i.e. levels of surveillance/visibility, ward door-locking
policies, ward rules); the relationship and proximity between a victim and aggressor; and the
extent of social support both within the ward with staff and patients and outside the ward with
family and friends. Although we have identified a number of demographic factors that are
associated with inpatient violence, the utility of these for an actuarial based risk assessment
tool is questionable. The generally small effects found coupled with the heterogeneity
between studies, suggest that any such instrument would be too inaccurate to be useful.
Approaches based on short term prediction may prove to be more practically useful
(Abderhalden et al., 2004; Ogloff & Daffern, 2006).
There is a significant debate in the literature about the link between schizophrenia, substance
misuse and violence in the community and this review is consistent with research which has
found associations between these variables (Fazel et al., 2009). The mechanism of the link
between substance use, schizophrenia and aggression is uncertain as they share a number of
confounding risk factors such as male gender, younger age, increased suicide rate, non-
adherence to treatment, higher levels of social deprivation. Common factor models suggest
the links are the result of shared risk factors such as genetics, antisocial personality disorder,
socioeconomic status an impaired cognitive functioning. Secondary substance use models
posit that there are certain reasons (self medication, alleviation of dysphoria) why having a
diagnosis of schizophrenia increases the risk of substance misuse. Secondary psychiatric
disorder models put forward the opposite argument that substance misuse leads to a diagnosis
of schizophrenia in individuals who would not have developed the disorder had they not
taken illicit substances. In addition there are bidirectional models that propose that either
variable (schizophrenia, substance misuse) can increase the likelihood of the other co-
occurring (for a review of the evidence for and against each model, see Mueser et al., 1998).
Future research is needed that follows patients longitudinally to shed more light on the
direction and relationships between aggression and the significant demographics identified
here (age, gender, history of previous violence, history of substance misuse, type of
admission, diagnosis, marital status). This in turn may provide useful information about
which of these factors reliably predicts an aggressive patient. It may be possible to then start
thinking about management strategies for these patients. What is it about a young, single,
male admitted involuntarily with a diagnosis of schizophrenia and a history of previous
violence, self-destructive behaviour and substance misuse that makes an aggressive incident
more likely? Potentially the way in which staff make requests of a patient could be a potential
antecedent of an aggressive incident. Requests may be perceived as demands and feel a lack
of control over their environment or their actions. This may be attenuated by a lack of social
support, and symptomology such as delusions and irritability.
7. THE TIME AND PLACE OF VIOLENT INCIDENTS

The literature review on violence and aggression identified 78 papers which contained
empirical data on the time and place of violent incidents. Most studies were from the USA
(n=24) or the UK (n=22). Six were from Australia and three from Canada, Italy, New
Zealand, Norway and Taiwan. Twenty studies were from acute wards, 22 from forensic
services, and 34 from a mix of wards in psychiatric hospitals. Two were categorised as
other.
7.2 Time of day

Only studies which specified the time of day in which violent incidents occurred or reported
the time of peaks in incident rates were included in this section (n=57). The time categories
employed by these studies varied widely. These often reflected shift patterns specific to
individual hospitals or were constructed for analytical convenience. This makes aggregating
data across studies particularly difficult. Our approach was to categorise peaks of incidents
by either shift or time interval. If data was available for both, only the time interval data (i.e.
the most specific timing) was analysed. The time intervals with the best fit across all the
studies were: 6:00-7.59, 8:00-11.59, 12:00-13.59, 14:00-17.59, 18:00-19.59, 20:00-21.59,
22:00-5.59 (night). These categories were applied with a degree of flexibility (plus or minus
one hour) in order to capture all the available data. Data presented in the form of two shifts
(day or night) or three shifts (morning, afternoon/evening and night) were also extracted, as
were specific activities associated with peaks of incidents (e.g. mealtimes).
The frequency of studies which reported peaks of violence within each time category or shift
were calculated. Where studies reported two or more peaks of incidents during the day each
was included in the calculations. It was much more difficult to examine actual rates of
violence by shift or time. Studies typically mentioned times of peak rates of violence, rather
than report rates across a complete 24 hour period. Therefore, insufficient data was available
for this kind of analysis
A total of 27 papers reported specific times of day when higher rates of violent incidents
occurred. As Figure 1 shows, incidents tended to peak between 8am and 8pm, with none of
the studies reporting a peak during the night. The most frequently reported peak of violence
was between 8:00 and 11:59 (n=13), with a reduced frequency for each subsequent category
thereafter.
A further 30 studies reported high rates of violence during certain shifts (Figure 2). Again,
no studies reported a peak during the night. In contrast to the time based analysis, most peaks
were found in the afternoon/evening shift (n=15). However, studies restricted to analysis of
violent incidents by shift may well have missed more subtle variations in the distribution of
violence during the course of the day.
Figure 1: Peak times for violent incidents
14
12
10
Frequency
0
6:00-7:59 8:00-11:59 12:00-13:59 14:00-17:59 18:00-19:59 20:00-21:59 22:00-5:59
Time
Figure 2: peak shifts for violent incidents
16
14
12
10
Frequency
0
Day Morning Afternoon/evening Night
Shift
There was a difference by setting in the proportion of peak times for violence which occurred
before midday, with studies from psychiatric hospitals reporting a higher percentage (63%)
than acute (29%) and forensic (23%) services. Similarly for analysis by shift, 50% of peak
times for violence were on a morning shift in the psychiatric hospital studies, compared to
33% in studies of acute wards and 17% in forensic studies.
The timing of peaks in violence may be related to levels of patient activities on the ward, staff
handover, medication round, meal times or waking time. These all place demands on patients
which may trigger a violent incident. Ten papers specifically stated that meal times were
high risk periods for violence. This was usually an association with mealtimes in general
(n=8), but where papers were more specific they were not entirely consistent. One study
from the USA found that violent incidents peaked sharply in the morning before breakfast,
but rates of incidents were then fairly consistent throughout the day [Abbott 1978]. In
contrast, a prospective study from Australia reported that fewer incidents occurred at
lunchtime compared to the morning or evening periods [Owen et al. 1998].
Two forensic studies reported that staff handover times corresponded to high levels of
violence and aggression. One was from Finland and found statistically significant higher
rates of violence during 1-3pm which was the time for nursing handovers [Weizmann-
Henelius and Suutala 2000]. The other identified the night-shift handover (9pm) as a
particular risk period for violence [Gudjonsson et al. 1999] and was also the only study to
report a peak of violence at medication times. In addition, a prospective survey of incidents
in a psychiatric hospital found that a fifth of incidents occurred in the first hour of a shift
[Yassi et al. 1998].
Explanations for these associations were less forthcoming. It may be that peak times for
patient violence are related to activity demand changes, particularly when patients are
requested to become active after a period of inactivity such as mealtimes [Depp 1976].
Alternatively, it has been suggested that more incidents occur in the early afternoon because
nurses are least available to patients during this time and there is increased interaction
between patients [Whittington and Wykes 1994]. This is supported by another study which
found less violence during early morning and evening periods when staff were maximally
available to patients [Fairlie and Brown 1994]. Weekends may have fewer incidents simply
because they are less hectic than weekdays [Gudjonsson et al. 1999]. One analysis of
mealtime incidents found a greater number to occur when patients were walking or standing
in line (54%) compared to actually sitting in the dining room (35%)[Hunter and Love 1996].
Mealtimes involve most patients congregating in the same place which may create tension, on
top of any irritability associated with hunger [Gudjonsson et al. 1999].
Most studies included both physical and verbal aggression, but no differences were reported
in terms of the relative timing of these incidents.
7.3 Day of week

Thirty-three studies reported the distribution of violent incidents by day of the week (Figure
3). Peak days for violence tended to be at the start of the week (Monday, Tuesday and
Wednesday), with no studies reporting a peak on Saturday, although three reported a peak on
Sunday. Some studies (n=9) compared weekdays to weekends and overwhelming found that
violence was more prevalent during the former. However, it should also be noted that a fifth
of the studies (n=7) reported no pattern to violence during the course of the week. The most
frequent category for studies of acute patients was Monday-Friday (n=3). For forensic
studies the most frequent peaks were Monday and Tuesday (n=3 each) and for psychiatric
hospitals it was Tuesday and None (n=4 each). One study reported frequencies by incident
type [Bowers et al. 2006]. It found that property damage was less frequent on Wednesday
and Friday, physical aggression to be lower on weekends and Wednesday, but no significant
pattern for verbal aggression or self-harm.
The most common explanation provided for differences by weekday concerned greater levels
of association between patients and staff during the week compared to the weekend. Patients
are involved in more activities, there is greater movement around the ward and higher staff
levels so there is more interaction with staff and more staff around to notice and report
incidents [Abbott 1978]. Other explanations for fewer incidents at weekends include patients
having the option of not going to the dining room [Hunter and Love 1996], lower levels of
patient activities [Carmel and Hunter 1989], and fewer procedures carried out and decisions
made [Morken et al. 1999]. Explanations for the prevalence of violence on specific
weekdays involved the routines of the ward or hospital. This included patients assembling to
watch films [Dietz and Rada 1982], visiting days and unit meetings [Ionno 1983], and tension
associated with ward rounds [Cooper et al. 1983]. One acute ward study found levels of
verbal and physical aggression to be significantly more likely on the days before and after
ward rounds [Bowers et al. 2006], when patients may anticipate or react to significant
decisions about their care.
Figure 3: Peak days for violent incidents
10
6
Frequency
0
Mon Tue Wed Thu Fri Sat Sun Mon-Fri Weekend None
7.4 Month and season
Thirteen studies reported rates of violence by calendar month. Although the same months
were often cited, there was insufficient data for a clear pattern to emerge as to whether this
represented a peak or trough in incident rates (Figure 4). None of the studies reported a peak
in incidents between December and February and these months were cited as low incidence
months by three studies.
Figure 4: High and low rates of violence by month
2
Frequency
0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
High Low
One forensic study found a higher proportion of violent incidents to occur between April and
September because of higher bed occupancy during this period [Kennedy et al. 1995].
Another reported that monthly variations reflected rates per violent patient rather than more
patients being violent [Gudjonsson et al. 1999]. One study which examined rates by month
and season found no pattern by month or season [Dooley 1986].
Two studies found incidents in warmer months to be slightly lower than other times of the
year [Dietz and Rada 1982;Haider 1997]. A further six studies reported on seasonal patterns.
Two found no variation by season [Harris and Varney 1986;Noble and Rodger 1989]. One
found less violence during the autumn compared to other seasons [Weizmann-Henelius and
Suutala 2000] and two reported increased incidents in the winter [Coldwell and Naismith
1989;Stockman and Heiber 1980]. These patterns may not be stable: different peaks before
and after the closure and re-opening of a ward have been reported, with a shift from higher
rates in Spring to Autumn [Omerov and Wistedt 1997]. Finally, two further studies examined
rates of violence by lunar cycle and found no association [Grainger and Whiteford
1993;Owen et al. 1998].
7.5 Location of violent incidents

Eighteen studies provided sufficient information to categorise the most frequent location of
violent incidents or the proportion of incidents by location. The location most frequently
reported as having the most number of incidents was the lounge or day room (27%), followed
by bedrooms (23%), corridors (14%), nurse stations (14%) and unspecified common areas
(14%).
Twelve studies reported the proportion of violence incidents at each location (Figure 5). The
mean percentage of incidents was similar for bedrooms, corridors, lounge and nurses office
(between 24% and 28%), but dining areas and bathrooms had relatively low rates.
Comparison of the seven acute and forensic studies showed that lounge and nurses office
were the most frequent locations for the former, while the forensic studies typically reported
more incidents in generic communal and lounge areas.
Figure 5: Location of violent incidents
30
25
20
% 15
10
0
Bathroom Bedroom Corridor Dining area Lounge Nurse office Ward door
Location

There is a clear link between the degree of patient association and levels of violence. In
general, the more opportunity there is for interaction the greater the chance of violence
occurring. This explains the fewer incidents reported at weekends when wards tend to be
quieter and there are fewer activities for patients to engage in. Less stress, noise and bustle at
weekends reduces the chances of aggression and violence occurring. These findings were
reported by studies of both patient-patient and patient-staff violence and those which
focussed on violence against staff only. Taken together, the best it is possible to conclude
from the studies is that the routines and organisation of the ward can influence the rate of
violent incidents. Mealtimes, staff handover and group activities area associated with an
increased risk of violence. It may be possible to organise these interactions differently to
reduce tension or opportunities to commit violent acts, but from the papers reporting violence
against staff it does seem that patient-staff interactions can be associated with violence also.
Of course, what all the papers lack is an assessment of the manner of the interaction between
staff and patients rather than simply the circumstances or frequency of it. A greater presence
of nurses at some periods of the day may simply increase the opportunity for an aggressive
patient to verbally or physically abuse them. On the other hand, there is evidence that staff
presence reduces the risk of violence. For example, one multi-site study found lower levels
of violence in a PICU, possibly reflecting the nurses expertise in handling aggressive
behaviour, and overall levels of violence to be lower at times when staff are most available to
patients [Fairlie and Brown 1994].
The notion that increased staff presence raises the risk of violence was further examined in
the literature. Twelve studies examined the relationship between staffing levels and violence
(surveys of nurses and patients perceptions of this issue were excluded). However, the
collective findings are inconclusive. Three studies found no overall association between
staffing and violence levels [Depp 1983;Lanza and Kayne 1997;Palmstierna and Wistedt
1995]. Four reported that more staff to be associated with greater violence [Bowers et al.
2009;Carmel et al. 1991;Morrison 1990;Owen et al. 1998] and another four found a negative
association [Bowers et al. 2007;Chou et al. 2002;Fairlie and Brown 1994;Jones 1985]. In a
further study, the relationship between staffing numbers and violence was negative for
permanent staff but positive for temporary staff [James et al. 1990]. Whilst reporting no
apparent relationship overall, one study found it to be positive for inter-patient violence but
negative for patient-staff violence [Palmstierna and Wistedt 1995]. Another of the studies
which found no overall effect reported differences in the direction of the relationship between
staffing and violence between individual wards [Lanza and Kayne 1997].

The City model does not include the kinds of temporal effects described here. However, the
evidence from this review suggests that observed variations by time actually reflect aspects of
service organisation.
7.8 Discussion
Summary
The evidence available in the literature suggests that time and place have some association
with levels of violence on wards, but the way in which this happens is most likely to be
related to the specific configuration of individual services. There is no compelling evidence
for seasonal effects, but peaks in violence by time of week and day seem to correspond with
particular events and activities on the wards. Incidents occur in most areas of the ward, but
particularly in corridors, bedrooms, lounge areas and around nursing stations.
Lessons for future research

We know from the literature that small numbers of patients are responsible for the majority of
violent incidents. In light of this, it is not clear how the findings for time and place should be
interpreted. Are we to conclude that only certain patients are likely to find social situations
stressful or difficult to cope with (e.g. mealtimes)? Perhaps patients with a propensity for
violence deliberately plan attacks to occur at particular times and places. None of the studies
address these issues.
Given the links between service organisation and violent incidents, as well as evidence of
setting differences in the timing of violence, local assessment of the time and place of
incidents may facilitate initiatives to reduce violence on wards. Such initiatives are unlikely
to work unless more is understood about the nature and content interactions between patients
and staff which occur at specific times and places. Further exploration of time and place by
victim type (patient or staff) would be a useful and achievable starting place for future
studies.
8. STAFF AND PATIENT PERCEPTIONS OF VIOLENCE AND
AGGRESSION

Sixty four papers were identified that address staff and patient attitudes and perceptions of
aggression in inpatient psychiatry. 43 papers contained information on staff perceptions, 9 on
patient perceptions and 12 had information on both staff and patient perceptions.
Type of wards
Seven studies collected data from acute settings, six from forensic settings, twenty four from
more than one inpatient setting, two studies collected data from psychiatric intensive care
units, twenty collected data from non specified wards (10 psychiatric hospital/institutions, 3
unspecified psychiatric units, 6 cross sectional surveys of staff) and five collected data from
other types of wards (1 chronic long stay setting, 1 closed psychosis wards, 1 psychiatric unit
in general hospital, 1 veterans medical centre, 1 psychiatric nurses college).
Countries
Data were collected from 14 different countries. These were: UK (24 studies), USA (n=19),
Netherlands (n=6), Australia (n=5), Sweden (n=3), Canada (n=3), Switzerland (n=3), Taiwan
(n=2), Spain, Turkey, Norway, Germany, South Africa and China (n=1).
Data source
There were five methods of data collection used. Data were collected from questionnaires (n=
41 studies), interviews (n=29), observations (n=2), focus groups (n=3) and video footage
(n=1). Thirty papers employed quantitative methods of data collection, 27 used qualitative
methods and 7 used a mixed methods approach.
Sample
The number of staff members who took part in these studies ranged from 4 to 3074 and the
number of patients from 4 to 1386.
8.2 Method
A thematic analysis of the staff and patient perceptions, attitudes and belief data produced 11
distinct lower-level themes which formed 4 higher-level themes: perceptions of aggression,
aggression facilitators, preventing aggression and reaction to aggression. These themes will
now be discussed in terms of both staff and patient perceptions.
8.3 The function of aggression
This section presents literature on psychiatric staffs perceptions of the function of
aggression.
Quantitative findings
Nine studies (Jansen et al, 1997; Jansen et al., 2006a, Jansen et al., 2006b; Jonker et al., 2008;
Muro et al, 2002; Palmstierna and Barredal, 2006; Whittington and Higgins, 2002;
Alderhalden et al., 2002; Whittington, 2002) quantitatively explore staff perceptions of the
function of aggression by psychiatric patients. Jansen et al (1997) asked 274 psychiatric
nurses to rate 60 descriptions of aggression (that had been generated during a qualitative
study with nurses, Finnema et al 1994). A factor analysis of these ratings produced three
distinct dimensions of aggression. Nurses perceived aggression as either a normal reaction
to feelings of anger, aggression as a violent reaction or aggression as a functional reaction.
A follow up study surveying 618 psychiatric staff in the Netherlands (Jansen et al 2006a)
investigated whether staff characteristics may underlie differences in perceptions of the
function of aggression. Staff working with geriatric patients, on long stay wards, and those
who used restraining interventions were found to agree with the violent reaction attitude.
Male nurses, those working daytime shifts and those working in geriatric psychiatry agreed
that aggression was a normal reaction. Female staff, those working in child and adolescent
services, on short stay wards, those who worked on both day and evening shifts were the
strongest predictor of perceiving aggression as functional reaction. Nurses with more than
11 years of experience agreed less often than less experienced nurses that aggression was a
functional behaviour. Using the Attitudes Toward Aggression Scale (ATAS) (Jansen et al,
2006a) which comprises five types of attitudes towards aggression; offensive,
communicative, destructive, protective and intrusive attitudes, Jansen et al (2006b)
investigated the attitudes of 1963 nurses internationally. Men were found to agree more with
the communicative scale than female nurses but less on the destructive scale. Nurses who
worked part time had lower scores than full time staff on the offensive, destructive,
protective and intrusive attitudes. Using the same measure Jonker et al (2008) looked at
the prevalence of each function of aggression amongst 113 nurses in the Netherlands. The
highest scores were found for the view that patient aggression is destructive and offensive,
and lowest scores for the view that aggression is protective and communicative.
Three of these studies looked at differences in perceptions cross culturally. In the Jansen
study UK nurses had the highest score for the offensive and intrusive attitude scales and
the lowest scores for the protective attitude scale on which the Norwegian nurses scored
highest. UK, German and Norwegian nurses had higher scores on the destructive scale than
the Dutch or Swiss nurses. Alderhalden et al (2002) found that German nurses scored lower
on aggression as dysfunctional than nurses form other European countries who in turn
scored lower than nurses from non-European countries and in this study German nurses
scored higher on aggression as functional scale than nurses from other European countries.
In a comparison of UK and Chinese mental health nurses, Whittington and Higgins (2002)
found that UK nurses agreed significantly more than the Chinese sample with the notion that
aggression is something that can be tolerated, a notion that ties into viewing aggression as a
normal reaction.
Five of the studies employed the Perception of Aggression Scale (POAS) (Jansen et al, 1997)
to measure psychiatric staff perceptions of aggression. This measure also draws its statements
from the original attitude inventory from the Finnema study. Muro et al (2002) administered
the POAS to 90 nursing students in Spain, 48.9% scored between strongly agree and agree
with the perception that aggression is a violent reaction; this figure was 0% and 6.7% for
normal reaction and functional reaction. There was a significant difference between
gender and perception of aggression as a violent reaction with females in stronger
agreement than males.
Whittington (2002) investigated the normal reaction to aggression attitude with 37 UK

nurse. Nurses with 15 years or more experience agreed with this attitude more than nurses
with less experience. This study also found that staff with lower burnout scores supported the
view that violence is a normal reaction more than those with higher burnout scores.
Similarly, Whittington and Higgins (2002) found that attitudes regarding aggression as
positive were related to a sense of personal accomplishment at work in a sample of mental
health nurses in the UK and China. In contrast to Whittington (2002), Adberhalden et al
(2002) found more experienced nurses had higher scores on the attitude that aggression is
dysfunctional than less experienced nurses. Older nurses also rated this function higher than
younger colleagues. Diploma nurses scored lower on the aggression as functional scale than
nursing aids and students. Palmstierna and Barredal (2006) found that more agreement with
aggression as a protective measure was related to older age and more experience of
aggression management training, and that male nurses with longer experience tended to
regard aggression more negatively on the aggression as dysfunctional factor.
Qualitative findings
Three papers qualitatively explore staff perceptions of the function of aggression. Finnema et
al (1994) conducted interviews exploring the characterisation and perception of patient
aggression by twenty four nurses working in a psychiatric hospital in the Netherlands. This
study shows that nurses perceive and describe aggression in a number of ways. As well as
negative views about aggression, most nurses acknowledged that aggression also has positive
features. This is illustrated in respondents descriptions of aggression which included,
aggression as a way to express feelings, aggression as a way to get things done which
would otherwise not have been done. Five categories of aggression emerged from the
definitions given by staff. These were definitions that contained a value statement, a form of
aggression, feelings that aggression evokes, the function of aggression and consequences of
aggression.
Daffern and Howells (2009) conducted semi-structured interviews with psychiatric staff, and
where possible with patients, at a personality disorder unit in the UK. They were asked to
recall and describe an incident of aggression and these descriptions were scored for the
presence or absence of a particular function as classified by the Assessment and
Classification of Function (ACF) tool (Daffern et al., 2006). Incidents of aggression were
viewed by staff and patients as multi functional with each incident containing a median of
three functions. Most incidents involved the expression of anger (97%), 58% were expressed
as tension reducing and as a means to enhance status or social approval and 42.42% had a
demand avoidance function.
A phenomenological study by Cutcliffe (1999) highlights the individualistic nature of nurses

views about aggression. In relation to the same patients aggression one nurse stated I would
not consider his behaviour to be violent, It was his way of telling us that he is pissed off
another nurse described this patients behaviour as, I would say that is violent, sureI report
that as a violent outburst. An interesting theme emerging from this study was the way nurses
decided on what they regard as violent. Intent, the extent of the therapeutic relationship a
nurse has with a patient and the focus of the patients violence were described by staff. What
I report as violence depends upon my previous experience of violence, what defines
something as violence is the intent, if I get the sense that the violence is pre-meditated, this
makes it harder to be compassionate and empathetic.
8.4 Staff expectation of aggression
Seven quantitative studies (Baxter et al., 1992; Chaimowitz and Moscovtich, 1991; Poster
and Ryan, 1989; Schwartz and Park, 1999; Gordon et al., 1996; Collins, 1994; Poster, 1996)
report upon staffs perceptions of the expectation of encountering aggression during their
careers. These studies show that a number of mental health workers expect to encounter
aggression during the course of their role caring for the mentally unwell and some feel that
this is part of their job. Chaimowitz and Moscovtich surveyed 132 psychiatric residents in
Canada about their experience of aggression by psychiatric patients, 40.2% of residents had
been assaulted at least once during their training and 45.3% of those assaulted believed that
being assaulted was part of the risks of psychiatric practice. Similarly, Schwartz and Park
(1999) surveyed 517 psychiatric residents in America and 12% felt that being assaulted by
patients is an inherent part of the profession. Four studies asked staff to rate whether they
agreed or disagreed with the statement staff working with mentally ill patients can expect to
be physically assaulted at some point during their career. Eighty five percent (n=263) of
psychiatric nurses in Australia (Baxter et al., 1992), 75% of psychiatric staff in America
(n=184) (Poster and Ryan, 1989), 56% of health care workers (n=40) providing care
psychiatric inpatients in Australia (Gordon et al, 1996) and 73% of 999 nursing staff
surveyed in the United States, Canada, UK and South Africa (Poster, 1996) agreed with the
statement. Collins (1994) reported that before taking part in an intervention that addressed
the prevention and management of aggressive behaviour 51% of psychiatric staff and
students expected to be assaulted by patients in their career. Following training and
education this figure decreased to 39% which the authors attribute to staffs increased
confidence and reduced anxiety following training.
Two qualitative studies (Chen et al., 2007; Delaney et al., 201) report staff perceptions of
assaults as an inevitable part of a career in psychiatric care. Chen et al, (2007) interviewed
thirteen staff victims of psychiatric inpatient assault. The interviews revealed that staff
perceive aggression to be a common problem at work. In response to questions about the
experience of aggression one member of staff said 'we prepared in our minds to encounter
such events when we took the job as psychiatric nurse. It is very common to have such an
assault in a psychiatric ward.' Another said, 'It was natural to be physically attacked as a
psychiatric nurse. Staff who took part in focus groups conducted by Delaney et al (2001)
discussed the expectancy of being assaulted. An interesting view raised during these
discussions was that perhaps expecting to be a victim of aggression may in fact lead to being
assaulted. This self fulfilling prophecy effect was described by one staff member as; 'Do we
want to say acute nursing aggressive incidents will happen...that's a fact of life'well
actually no it's not part of the job, like it's not in my job description ...it's the general
attitude...that we will get assaulted...but maybe if we looked at the other way that we
shouldn't expect to get assaulted and it shouldn't happen...would that change things at
allMaybe...we are going to be assaulted...because we expect it to happen. This study also
sheds light on the fact that although nurses expect to be assaulted, they dont necessarily see
if as part of their job to be on the receiving end of aggression.
8.5 Causes of aggression
The characteristics of violent patients, staff characteristics, denying and the restriction of
patients, environmental factors and interaction factors were identified by respondents as
facilitators of aggressive behaviour.
Patient factors
Six papers addressed the role of characteristics of violent patients in facilitating aggression
(Chaplin et al., 2006a; Chaplin et al., 2006b; Gillig et al., 1998; Duxbury and Whittington,
2004; Duxbury et al., 2008; Duxbury, 2002) A study comparing the views of 32 staff and 54
patients regarding the causes of psychical aggression in a psychiatric unit reported that 50%
of staff and 65% of patients cited patient psychosis as a major cause of physical aggression
on the unit (Gillig et al.,1998). In three papers using The Management of Aggression and
Violence Attitude Scale (MAVAS) to evaluate staff and patient perspectives of violence in
mental health units (Duxbury and Whittington, 2004; Duxbury et al., 2008; Duxbury, 2002)
staff viewed patient internal factors as causes of aggression. However, two of these papers
compared staff and patient views (Duxbury, 2002; Duxbury and Whittington, 2004) and
found that the ratings of agreement to the statement patients are aggressive because they are
ill were significantly lower for patients than for staff.
The use of substances by patients is referred to by respondents in three of these studies. The
use of drugs and alcohol was rated highly by staff and patients as causes of aggression in the
study by Gillig. 43% of patients and 74% of staff believed patients using drugs or alcohol,
patients who sell drugs and alcohol (35% v 49%) and patients who are intoxicated (44% v
77%) were major causes of physical aggression on the units. Interestingly, 33% of patients
and 3% of staff believed that staff who use drugs and alcohol was a major cause of
aggression. Patient intoxication as a cause of aggression was also reported in a large national
audit study of 3074 staff and 1386 patients (Chaplin et al, 2006b). Sixty-one percent of nurses
believed that there was trouble on the ward because of alcohol (compared to 25% of patients)
and 72% of nurses said that they thought trouble on the ward was caused by drugs (compared
to 29% of patients).
However, in an audit study with 585 staff and 157 service users only 5% of staff and 7% of
service users affirmed the question is there trouble because of people getting drink? and
only 4% of staff and 5% service users agreed that there [is] trouble because of people taking
drugs? (Chaplin et al, 2006a).
In six interview studies (De Neit et al., 2005; Duxbury and Whittington, 2004; Lanza, 1998;
Kindy et al., 2005; Spokes et al., 2002; Finnema et al., 1994) nurses reported that psychotic
symptoms are often precursors to aggression. Nurses in the study by Kindy cited
characteristics of psychiatric and developmental disorders including impulsiveness,
explosiveness and feeling superior to and antagonistic toward staff as contributing factors to
the uncontrollability of the environment. Nurses in the study by Finnema described patient
hallucinations, delusions and inability to express angry feelings in other ways as factors
contributing to violence. In the study by De Neit nurses talked about not always being able to
understand a patients reasons for their aggressive behaviour, and related this to the patients
psychosis and impulsivity.
In a small interview study with 4 staff and 4 patients (Hinsby & Baker 2004), the patients
talked about their unstable mental state as a reason for violence, this is illustrated in the
following quote from a patient in the study; When your mental state is all right you know the
difference between right and wrong; even if you are angry you can control yourself. But when
you are not stable and you are a paranoid schizophrenic, little things spark you off.
However, in an interview study (Johnson et al., 1997) with twelve thought disordered patients
only two attributed the cause of violence to internal factors, the patients in this study more
frequently described external factors as reasons for their aggression. Ninety two patients were
interviewed about their views on the causes of patient- to-patient and patient-to-staff
aggression in a study by Fagan-Pryor et al. (2003). Internal factors including cognitive
factors, feelings and symptoms were described by 33% of the patients as contributing to
patient-to-patient aggression, and by 39% in relation to patient-to-staff aggression. Cognitive
factors included, the aggressive patient thinking everyone is against him or her; feeling
disrespected, not understanding why he or she is hospitalised and not being in the right frame
of mind. Jealousy, anxiety, frustration, emotions not being right, alcohol depression, anger,
boredom and irritability were examples of the feelings patients viewed as causing aggression.
And symptoms included hallucinations; talking too much without stopping; losing control
because one is not in touch with reality and incoherence. Meehan et al (2006) conducted
focus groups with patients in a high secure forensic mental health facility to capture patient
perceptions about the factors leading to aggressive behaviour. Personal characteristics of the
patients emerged as a theme from the discussions. The impulsive and demanding nature of
some patients was described as a source of tension in relationships between patients, and
patients and staff. There was a perception that some patients have a short fuse and they lose
control very quickly which was attributed to illness factors. One patient described difficulties
in controlling aggressive outbursts; sometimes Im ready to explode I get so annoyed with
some of the other patients . . . and the staff too. Its not easy to control myself but I have to
control it.
The use of drugs and alcohol by patients was described as contributing to violence in two
studies (Spokes et al., 2002; McGeorge et al., 2000). In an audit study of psychiatric staff,
patients and visitors from 42 NHS Trusts in the UK (McGeorge et al., 2000) staff reported
that even when alcohol and drugs were not readily available on the wards, problems would
occur when patients returned to the wards having consumed them off the premises. In free-
text responses to questions about the triggers of aggression, 16% of patients and 29% of staff
in the study by Chaplin et al (2006b) mentioned illegal drugs and alcohol. Other patient
factors described as causes of violence include involuntary admission status, a history of
violence as mentioned by staff (Delaney et al., 2001; Finnema et al., 1994) and patients
(Omerov et al., 2004), and mix of patients with different diagnosis and mental health
problems on the same ward (McGeorge et al., 2000; Quirk et al 2004).
Staff factors
A survey of 263 psychiatric nurses using the Attitudes to Assault Questionnaire (Baxter et al.,
1992) found that 70% of nurses agreed that behaviour and attitudes of staff can invite assaults
from patients. In contrast, several studies (Bilgin & Buzlu, 2006; Poster & Ryan, 1994; Poster
& Ryan, 1989) who administered the Attitudes Toward Patient Physical Assault
Questionnaire (ATPPAQ) to psychiatric staff found a strong disagreement with statements
pertaining to patient aggression being related to staff competency, skills and personality. For
example, 78% of 162 Turkish psychiatric nurses (Bilgin & Buzlu, 2006) and 75% of 184 staff
working in a psychiatric hospital in the USA (Poster & Ryan, 1994) did not agree with the
statements staff members who are assaulted have personality traits that make them
vulnerable to patient assaults, patient physical assault of a staff member is a result of
performance deficiency (88.3% and 78% respectively), or staff members who are physically
assaulted are less competent clinically than staff who are not assaulted (80.9% and 92%).
However, in this American sample male staff were significantly more likely than female staff
to believe that assaulted staff had personality traits that made them vulnerable to assault (14%
vs 5%).
Unlike the majority of the quantitative studies reported above, nine qualitative studies report
that staff characteristics, behaviours and attitudes can lead to patient aggression. In a study
conducted using semi structured interviews (Bond and Brimblecomb, 2003) with 102 English
psychiatric nursing staff, 96.1% of staff reported that individual characteristics of staff
increase the likelihood assault. Staff factors that were most frequently cited as increasing the
risk of violence included a lack of skills including communication, understanding and
attentiveness; personality characteristics including being overly opinionated, controlling,
eager or shy; and attitudes including rudeness, sarcasm, belittling, ignoring and arguing. In a
focus group study (Kumar et al, 2001) with six mental health service users who had
experienced aggression reported that stressed staff, staff attitudes, being treated
disrespectfully by staff and a decline in staff caring attitudes were all precipitants to violence.
Omerov et al., (2004), interviewed patients who had been involved in violent incidents about
the causes of their aggression, in 73% of the incidents patients considered that the violence
was provoked by staff.
Spokes et al., (2002) obtained views of 108 mental health nurses about the role of staff
related factors in violence. The nursing staff interviewed believed that staff factors affect the
likelihood of a violent incident occurring. Staff factors that were reported as affecting the
likelihood of violence occurring included staff clinical skills, such as competency in the use
of techniques such as distraction, interpersonal skills such as verbal and non-verbal
communication, including providing explanations and being able to build rapport with
patient; and personal characteristics including physical characteristics, personality traits and
behaviours. Madden et al (1976) surveyed 115 psychiatrists about assaults by patients. 53%
of respondents believed that they had provoked the patient into attacking them by making
comments or interpretations that were received unfavourably by the patient and at times felt
they had been too insistent that a patient confront upsetting material. Several of the
psychiatrists reported that they did not particularly like the patient who assaulted them and
might have projected this feeling to the patient.
Other staff factors contributing to aggression that were reported in the qualitative literature
included, professional elitism, staff disrespect for ethnic, racial and gender issues,
competitive tensions among staff '...and we have a lot of pettiness among the treatment team,
a lot of egos...my degree is better than yours, or I have more experience.' (Kindy et al.,
2005), staff not being adequately trained, staff treating patients disrespectfully, staff not
paying enough attention to patients (Bensley et al., 1995), staff allowing patients to
antagonise each other (Quirk et al., 2004), deliberately provoking patients, not understanding
and neglecting patients and being aggressive towards patients (Finnema et al., 1994).
Interaction factors
Using the Management of Aggression and Violence Attitude Scale with mental health nurses
in Switzerland and UK Duxbury et al (2008) found that both samples of nurses agreed with
the statements that poor communication between staff and patients leads to patient
aggression and improved one to one relationships between staff and patients can reduce the
incidence of aggression. Using the same measure with staff and patients Duxbury (2002)
recorded differences in opinion between these two groups with regard to interaction between
staff and patients causing aggression. This view was supported by the patient scores on this
statement however, staff did not view their interactions with patients to be problematic or a
cause of patient aggression.
Eight qualitative studies (Duxbury & Whittington, 2004; Johnson et al., 1997; Fagan-Pryor et
al., 2003; Meehan et al., 2006; Finnema et al., 1994; Spokes et al., 2004; De Neit et al., 2005;
Duxbury, 2002) report that interaction between staff and patients can facilitate aggression.
Duxbury and Whittington (2004) reported that poor communication, specifically staff failing
to listen to patients, was commonly reported by patients as a precursor to aggression. 'People
in here just want to be listened to'. They don't seem to care. I don't think anyone trains them
in how to deal with people. Staff seem to think once you are in here they do not need to
bother There is no respect. Just because we are patients they think they can tell us to shut
up. Interestingly, the staff in this study did not view communication with patients to be
problematic. De Neit et al conducted a small qualitative study alongside a larger quantitative
study with nurse who identified several causes of aggression. They reported that the mutual
interaction between patients, interaction between patient and nurse and the so-called social
moments like drinking coffee and having dinner were often moments when aggression was
initiated. Finnema et al (1994) interviewed twenty four Dutch psychiatric nurses about their
perceptions of the causes of violence by patients. The respondents related aggression to an
inadequate attitude of nursing staff including not listening to patients, deliberately provoking
patients and interrupting patients. Meehan et al (2006) conducted focus groups with patients
about the causes of aggression on the unit. A major theme to come out of these focus groups
was that the way in which staff interacted with patients was a major source of dissatisfaction
for the patients. Staff were perceived as adopting superior attitudes and controlling
behaviours to enforce a strict hierarchy of authority rather than to assist in the delivery of
therapeutic care: you just get a lot of smart-arse comments from them [staff] and not much
caring. Some of them [staff] act as if theyre in a prison, prison guards, walking around all
day giving us an ear-full of what we can and cannot do. There was also a feeling that staff
lacked understanding about the problems associated with their illness and treated them with a
distinct lack of empathy. The perceived lack of caring gave rise to thoughts of harming staff
and retaliatory aggression.
Denying, restricting and imposing rules on patients
Four quantitative studies (Gillig et al,. 1998; Ruben et al,. 1980; Schwartz, and Park, 1999;
Lanza, 198) report that patient frustration borne out of actions such as limit and rule setting
and refusing patient requests is a precipitant to aggression. Ruben et al., (1980) conducted a
study with fifteen psychiatric residents who had been attacked by patients, 93.4% believed
they had done something to trigger the attack; the most common reason was that they had
frustrated the patient who had attacked them. Frustrations that were listed included setting
limits on patients, especially on issues around admission and discharge, carrying out physical
examinations on patients who didnt want them and making patients attend group therapy
sessions. Refusal to satisfy a patient request and setting limits on patients were recorded as
reasons for patient attacks on staff during a survey of 517 psychiatric residents (Schwartz &
Park 1999). Nineteen percent thought they had been assaulted because they had refused a
patient request and seventeen percent because they had set a limit on the patient. Gillig et al.,
(1998) reported that refusing a smoking requests, leave or discharge and forcing patients to
take medication were common causes of physical aggression by patients reported by 32
nursing staff (which country?). In an audit survey of 184 psychiatric wards (what country?)
9% of the patients surveyed reported that staff inadvertently provoke violence by restricting
their freedoms (Chaplin et al., 2006b).
Five interviews studies with staff (Finnema et al., 1994; Spokes et al., 2002; Madden et al.,
(1976); Secker et al., 2004; Chen et al., 2007) and one focus group study (Delaney et al.,
2001) revealed that denying a patient something they have requested or limiting and
restricting their freedom are often perceived as causes of aggression. Of the 108 mental
health nurses interviewed about the causes of violence by Spokes et al, 9% of staff thought
violence was related to staff employing limit-setting techniques with patients. Nurses in the
study by Finnema described constantly imposing restrictive measures on patients, limitations
among patients, the fact that patients are forced to conform to unit rules and the lack of
freedom for patients to do what they want are causes of patient aggression. Madden et al,
reports the views of clinicians that refusing to meet a patient's requests, setting too many
limits on a patients as well as interestingly, not setting enough limits are triggers to patient
violence. Secker et al interviewed 15 staff about the cause of 11 specific violent incidents that
had occurred on a psychiatric ward in the UK. Themes that emerged from several of the
incidents centred on staff denying patients requests, for example, requests to see a doctor,
access to the office, access to a telephone, and requests to be discharged. In four of these
studies (Spokes et al., 2002; Madden et al., (1976); Secker et al., 2004; Chen et al., 2007),
administering medication or checking that patients have taken their medication was identified
by staff as other triggers of patient aggression.
Evidence from four qualitative studies with patients (Omerov et al., 2004; Johnson et al.,
1997; Duxbury, 2002; Meehan et al., 2006; Bensley et al., 1995) support the role of
frustration, denial, and medication in triggering aggression. Thirty seven (90%) patients in
the study by Omerov who had perpetrated aggressive incidents considered that their violence
had been provoked. In 73% of these incidents patients considered that the violence was
provoked by staff often when permission was denied, for example to take part in an activity.
In 34% of the incidents patients reported that the incident had occurred when medication was
being given. Meehan et al (2006) conducted focus groups with 27 patients in a forensic
setting to capture patient perceptions of the factors leading to aggressive behaviour. The
inflexible and strict way in which staff enforce ward rules was perceived as a source of
aggression. Frustration was expressed when staff appeared to override the rules and withdraw
patients privileges for no apparent reason: I was on the phone to my girlfriend, and ah I was
on there for two minutes and they made me hang up, youre allowed ten minute phone calls,
you know, and I gave them a big heap of abuse. Ward procedures such as queuing at the
office window to talk to staff were seen by patients as demeaning and the source of friction
amongst patients. Staff were portrayed as ignoring frequent requests for assistance as youve
got to beg these people 26 [swear word] times before you get anything. Almost all of the
participants identified boredom as a source of frustration and medication was frequently
blamed for taking control away from the patients resulting in outbursts of aggression: . . .
when they [nurses] try to give me something else I say hold on mate thats not my
medication. I have seen lots of arguments over medications that end up physical . . . you
know . . . take-downs, seclusion, the lot. Patients in the study by Duxbury viewed themselves
to be victims of the controlling style of nursing staff. Johnson reported that the policies that
restricted patient freedom seemed linked to anger and aggressiveness. And patients in the
study by Bensley believed that not enough explanation of the rules contributed to patient
assaults.
Environmental factors
Several studies report that the environment of the psychiatric hospital or ward can be
conducive to patient aggression. Environmental factors such as the lack of adequate facilities
(Chaimowitz & Moscovtich, 1991; Poster & Ryan, 1989), inadequate staff numbers (Poster
& Ryan, 1989; Bilgin & Buzlu, 2006; Chaplin et al., 2006a) the use of bank and agency staff
and overcrowding (Chaplin et al., 2006a) have been reported as contributing factors of
aggression on inpatient wards. Using the Management of Aggression and Violence Attitude
Scale (MAVAS) Duxbury et al., (2008) surveyed nurses in the UK and Switzerland about
their views of the antecedents to violence, the UK respondents agreed with the statement that
Patients are aggressive because of the environment they are in while Swiss respondents
disagreed. UK respondents were also more likely than the Swiss nurses to agree with the
statement If the physical environment were different, patients would be less aggressive
although this did not achieve statistical significance. A lack of activities resulting in boredom
and in turn aggression was cited by service users in an audit including 1386 patients as a
cause of aggression (Chaplin et al., 2006b). Although 63% were satisfied with daytime
activities and therapy, only 47% expressed satisfaction with evening activities and 41% with
activities during the weekend.
The findings from several qualitative studies report that environmental factors play a role in
facilitating inpatient aggression. Finnema et al., (1994) interviewed 24 nurses about their
perception of patient aggression; a lack of privacy for patients, environmental factors specific
to closed wards and lack of activities were cited as preceding factors to violence. The staff
and patients interviewed in a study by Duxbury & Whittington (2004) deemed environmental
factors to be problematic and precipitants to aggression; the nursing staff referred to the poor
ward design and a bad atmosphere We are fighting against a really difficult structural
environment. Currid (2008) conducted a phenomenological study with eight mental health
nurses in London. Several of the participants linked insufficient staffing with the high rates of
aggressive acts and believed that if there were more staff available to meet patients needs or
to support the staff who were dealing with the aggressive patients, incidents would decrease.
Staff in an audit study by Chaplin et al (2006a) also made the link between low staffing
levels, lack of activities, boredom, and the potential for violence. The major concern among
service users in this study was the lack of things to do. This is reflected in free-text responses,
which indicated problems with boredom, dislike of being on the unit, lack of or cancelled
activities, being locked up, and denial of access to money and cigarettes.
Twelve patients were interviewed by Johnson et al (1997). A main theme to come out of the
interviews was that patients felt that aspects of the environment were influential in
precipitating aggressive incidents and some of the participants perceived the aggressive
incident to be justified because of the intolerable aspects of the environment. These included
being confined behind locked doors, the inability to go outdoors and the lack of space and
freedom, one patient stated Well, when youve got up to 25 people living together in one
locked up unit, sooner or later sparks are going to fly. If anyone expects anything else they
should be locked up in here with us! Bensley et al (1995) interviewed 69 patients from eight
high assault wards in the USA about factors they believed contributed to the assaults, in order
of importance these were smoking and access to outdoors, not enough to do (boredom),
overcrowding, noise, amount of food and lack of daytime access to bedrooms.
8.6 Preventing aggression
Predicting aggression
Nurses in four studies express the belief that it is possible to predict patient aggression. Poster
& Ryan (1989) report that 43% of the nurses they surveyed agreed that prediction of patient
assault is within competence and ability of all psychiatric staff, similarly, 49% (n=132) of
psychiatric residents attacked by patients in a study in Canada felt the attack could have been
predicted (Chaimowitz and Moscovtich, 1991). Milius (1990) conducted a cross sectional
survey with 43 mental health workers in the USA to assess that predictability of aggressive
outbursts. Nurses were asked for their opinions on the predictability of aggressive behaviour
and were asked to identify signals they would use to assess impending patient aggression.
88.4% of the nurses believed it was possible to predict that a patient was at risk of showing
aggressive behaviour and 76.7% said imminent aggressive outbursts were predictable. The
most cited predictors of inpatient aggression were; patient agitation (74% of nurses stated
this), verbal hostility (53%), frustration (49%), non-compliance (49%) and family conflict
(44%). Collins (1994) conducted a questionnaire study that assessed nurses attitudes about
their ability to predict aggression before and after taking part in an educational programme.
The nurses agreement with the statement It is impossible to know when patients will
become aggressive decreased following training, suggesting that through training and
education nurses become more confident in their ability to predict aggression.
The majority of assaulted staff (n=40) in a study by Lanza (1983) believed there are certain
important cues that can be predictive of assault. These included patients speaking in a loud
voice and using demanding or threatening language, pacing, obstinance, using threatening
gestures, withdrawal, refusing medication, irritability, hostility, anxiety, anger, inadequate
number of staff, lack of male staff, high noise level and high activity level, situations in
which staff are not in control of the ward, and overcrowding on the ward.
Preventive measures
Bond and Brimblecomb (2003) surveyed 102 mental health nurses working in a range of
settings about factors they perceive to make violence less likely. The responses focused
around staff characteristics that could lessen the risk of assault. Seventy one percent of the
nurses reported that good communication skills including body language, good use of voice
and active listening made assault less likely. Sixty four percent felt that a calm manner,
confidence and not over reacting could reduce the risk of assault and 37.8% cited human
relation skills such as likeability, humour, courtesy, empathy, warmth and 31.6% cited
decisiveness, good organisational skills and having clear boundaries as factors that could
make violence less likely. Chaimowitz, G. & Moscovtich, A. (1991) reported that 24.5%
(n=132) of psychiatric residents who had been assaulted in psychiatric facilities in Canada
believed that trained backup staff may have prevented the incident or rendered it less serious.
Several quantitative studies report that training around aggression management isnt always
provided to all staff, and/or isnt always perceived by staff as being adequate to meet their
needs of dealing with aggression. Seventy seven percent of psychiatric staff and students
surveyed by Collins (1994) agreed with the statements that doing the wrong thing will make
a bad situation [with a patient] worse and someone who is good at recognising the signs can
tell when a patient is becoming agitated. However, many studies report that psychiatric staff
do not receive adequate training for these purposes. Gordon et al (1996) reported that only
over half of staff working in a psychiatric institution in Australia (n=40) believed they had
sufficient training in dealing with assaultive behaviour. Chaplain et al (2006b) reported that
even though 90% of the 3074 staff they surveyed had received training in the last 5 years to
deal with aggression, almost 40% of these nurses did not receive this training until after they
began working on psychiatric wards and 20% of the nurses reported that the training they had
received was not adequate to equip them to manage violence. Baxter et al (1992) surveyed
263 nurses about their experiences of aggression, 87% believed that nurses should regularly
attend workshops in aggression management, similarly 98% of 184 nurses surveyed by Poster
& Ryan (1999) agreed that staff should be educated about prevention & management of
assaultive behaviour as part of their in-service education.
Finnema et al (1994) asked 24 nurses working in a psychiatric hospital about the
interventions they use to prevent and stop aggression. Talking to the patient, distracting the
patients attention, comforting the patient and giving unexpected reactions were mentioned as
interventions used to prevent aggression as well as to stop it. Extra medication and locked
seclusion were also mentioned. Chen et al (2007) interviewed 13 assaulted psychiatric nurses
in Taiwan about their aggression prevention strategies. Responses included, pre-placement
training, promotion of good practices such as taking precautionary awareness 'before entering
the patient's room, be attentive to his condition. avoiding being alone, asking for the patient's
consent, 'If a patient is unwilling to follow your orders, do not rush it'. 'Do not directly touch
a patient without his consent.' and respecting the patient's human rights, 'keep a kind attitude;
do not raise one's voice.' Roper and Anderson (1991) conducted interviews with nursing
staff at one acute inpatient unit in America. Staff emphasised the importance of the structure
of the ward milieu, maintaining routines of daily activities for patients as well as staff,
keeping the environment as safe as possible by removing potentially harmful personal items
from patients, removing the patient from potentially harmful events and situations, 'talking
down the patient', or using chemical and/or physical restraints and regulating and supervising
smoking as powerful constraints on harmful patient behaviour. Ten nurses working in
psychiatric facilities in America were interviewed as a part of a phenomenological inquiry
about nurses' experiences working in environments where there is a high risk of assault
(Kindy et al, 2005). Nurses described taking personal precautionary measures to prevent
violence through specialised education and training including therapeutic communication,
body language, physical positioning, teamwork, methods of managing assaultive behaviour,
noting client histories, observing patterns of behaviour and use of medications. Nurses also
described the use of tangible devises such as walkie-talkies, cameras, seclusion rooms,
restraints, mirrors and medications as fortifications against aggression.
In a study with veteran psychiatric patients in America (Fagan-Pryor et al, 2001) 92 patients
were asked about their perceptions of effective interventions to prevent assaultive behaviour.
These interventions were grouped into interventions to prevent patient to patient aggression
and interventions to prevent patient to staff aggression. For the former type of aggression
patients described individual interventions such as, walking away; good personal hygiene;
staying with people who are like you; cooperative patient-staff interventions included,
communicating better; understanding each other; getting to know each other and
interventions by staff included, setting limits; having better or more staff to supervise or talk
with patients; having patients with the same problem together; getting rid of patients who
fight; Interventions for preventing patient to staff aggression included interventions by
individual patients such as, trying to change the subject; not messing with other patients;
talking with a health care professional; not arguing; recognizing that one has a mental illness
and needs medication and help, cooperative patient-staff interventions such as, everyone
forgiving the past and talking it out; and interventions by staff including being oneself; not
making promises you cannot keep; not having an attitude; being more understanding;
informing patients ahead of time of their rights, endless patience and understanding. Kumar
et al, (2001) conducted focus groups with 6 psychiatric patients about their experience of
violence on psychiatric units and their perceptions of how violence can be reduced. Views on
approaches to reduce violence included increasing staff service user interaction, the
recruitment of more staff and fewer agency staff, screen to recruit caring staff, staff should all
be trained to diffuse tension, more grounds and environment should be designed to facilitate
engagement between staff and service users and a system to address complaints and monitor
incidents. In a study designed to explore the experiences and feelings of patients which
precede incidents of aggression (Johnson et al 1997), 12 Canadian psychiatric patients were
interviewed. Patients spoke about strategies that they employed to keep their feelings under
control and prevent aggressive outbursts. These strategies included diversion, physical
activity I have two choices: one, act out, or two, go down and pump some weight . . . . or go
for a jog or something like that., avoidance and talking to someone If I get in difficulty, I
know I can approach a nurse and get calmed down or at least have someone to talk to as a
sounding board.
Delaney et al (2001) conducted focus groups with nursing staff in Australia about nurse
management of aggression, staff highlighted on-ward in-service education focusing on the
management of aggression as important and relevant tool in managing aggression. Staff
explained that in addition to providing information and skills enhancement this education
promotes teamwork, peer support and sharing. It also addresses contextual issues and
environmental factors associated with aggression. 'It is very important to do 'cause...it's
probably the only time all year when the senior staff here get to get together and discuss how
they feel about things and I think that is important. Spokes at al (2002) interviewed 108 staff
about their perceptions of their colleagues training needs. The most common needs identified
included crisis intervention and prevention training (n= 50), theoretical training (n= 33) and
interpersonal skills training (n= 34). One mental health worker interviewed in a study by
Conn & Lion (1983) who was seriously injured by a patient attack pointed out that nowhere
in her training program had the topic of how to assess or manage dangerous patients had been
discussed until after she was attacked. She felt that she might have unwittingly contributed to
the assault because of her naivet about dealing with potentially volatile patients.
8.7 Reaction to aggression
Ten studies (Lu et al., 2007; Gillig et al., 1998; Omerov et al., 2002; Lanza et al., 1991;
Lanza, 1998; Haffke and Reid, 1983; Lanza, 1983; Baxter et al., 1992; Rees and Lehane,
1996; Collins, 1994) describe emotional and social reactions of staff following an experience
of aggression. Among these studies, fear and anger were the most commonly reported staff
reactions to aggression. Gillig reported that 16% of 32 nurses reported anger towards the
patient who had assaulted them, Omervo found this figure to be around the third mark and Lu
surveyed 106 nurses from Taiwan who repored that anger was the most common reaction
amongst staff following an aggressive incident. In this study fear was described as the most
common social reaction by these nurses. Omervo reported that 36% of male staff and 17% of
female staff reported feelings of fear following an incident of violence, this difference
between genders was significant with men becoming frightened more often than women who
were significantly more likely to be surprised by the attack then men (30% vs. 6%). Staff in
four studies reported that experiencing aggression by patients impacted upon their work.
Forty three percent of the nurses in the study by Lu reported that they experienced discomfort
in caring for the patient who had assaulted them. Gillig reported that 12% of the 32 nurses
surveyed avoided contact with the patient who assaulted them, 15% wanted to leave their job
and 18% wanted to change professional fields and Lanza (1988) reported that 27% of
assaulted nurses said their view of the future had changed which included staff considering
leaving nursing, changing their job, retiring early, working in a less dangerous setting and
questioning the value of a job with these risks. Wanting revenge, negative physiological
reactions, stress, hopelessness, feeling shocked and insulted and depressed were other staff
reactions to aggression reported in these studies. Gillig et al (1997) also surveyed 54 patients
about their reaction to the experience of aggression. Twenty six percent said they had trouble
sleeping, 27% experienced a change in appetite, 33% suffered an increase of
depression/sadness, 34%felt feelings of anger or rage, 22% avoided contact with other
people, 21% wanted to leave hospital for good, 23% suffered with a physical illness.
Four quantitative studies report on staff perceptions of blame for the violent incident. Baxter
et al, (1992) collected the responses of 263 psychiatric nurses in Australia. Of these, 44%
believed that nurses were unfairly blamed by others for provoking assaults upon themselves.
Similarly, 58% of male nurses (n=34) working in a psychiatric hospital in the UK (Rees and
Lehane, 1996) felt that blame for the aggressive incident had been attached to staff. They felt
those on duty at the time were held responsible for the incident. All 34 males said they felt
they had failed the victims, conversely all of the female members of staff (n=16) who had
witnessed an aggressive event did not believe they had failed the victims. Chaimowitz and
Moscovtich, (1991) and Schwartz and Park (1999) conducted studies with psychiatric
residents in Canada and America respectively. Twenty five percent of the Canadian sample
and 16% of the American sample believed that they had been responsible for the aggressive
incident occurring.
Six studies (Currid, 2008; Kindy et al., 2005; Conn and Lion, 1983; Roper and Anderson,
1991; Chen et al., 2007; Lanza, 1983) qualitatively report the reaction of staff to experiencing
aggression. In five of these studies staff discuss the impact aggression has on their work.
During one open interview study (Kindy et al., 2005) ten nurses who had experienced
aggression on the wards described how the incident had left them feeling hypervigilant,
distrustful and fearful which resulted in poor morale. Several participants expressed a desire
to leave 'Im looking for a new job. Im finding that its just absolutely too much and I think
its asking too much and it is not a safe environment. Im worried about patient care. And
that will in turn reflect on my license.' Nurses also reported feeling that they had an internal
conflict regarding their nursing roles, 'When youre at work and you get hit or punched, I
dont know. . .it just kind of takes, takes a little part of you. I didnt feel like a nurse. I felt like
uh, I felt like an underpaid correctional officer. I didnt feel like this was nursing. In six
qualitative studies staff described feelings of fear, anxiety and stress following an incident of
aggression. Staff who took part in an in depth semi structured interview study to investigate
workplace violence with staff working with schizophrenic patients in Taiwan described
feeling, worried, and scared, fear of facing patients and experiencing nightmares. Other
staff reactions recorded by these studies included anger, hopelessness I dont know what we
are going to do with this patient, We have tried everything and he is still no better,
(Roper and Anderson, 1991) and denial I dont want to think about this (Lanza, 1983).

Two studies in the theme the function of aggression (Whittington, 2002 and Whittington
and Higgins, 2002) found a relationship between the way staff perceive aggression and levels
of burnout. Nurses in these studies who held more positive perceptions of aggression were
less likely to experience burnout and had greater feelings of personal accomplishment with
their work. This is evidence for the role of psychiatric philosophy. The capacity to understand
aggression in psychological terms leads to positive attitudes and impacts which is displayed
by staff feeling less burnt out when working with aggressive patients and experiencing
feelings of personal accomplishment.
A number of studies reported that staff characteristics, especially clinical skills and ability
can influence patient aggression. This finding is in line with the models main assumption
that staff can directly influence aggression in inpatient settings through their psychiatric
philosophy, moral commitments to patients, the use of cognitive-emotional self management
and technical mastery. Moreover, literature in the subtheme of interaction pointed to the
role of poor interaction between staff and patients as a contributing factor in the occurrence
of aggression. A lack of understanding and respect by staff towards patients was reported as
causing incidents which could be attributed to staff lacking positive appreciation of patients.
The City model suggests that an effective structure on the ward including the way in which
staff manage the restriction of patient behaviours, freedoms and the denial of patient requests
can modify conflict. This review found that placing limits on patients, restricting their
behaviours and denying requests were all perceived as antecedents to aggression by staff and
patients. Importantly, several studies reported that the way staff manage these events can
influence the occurrence of aggression. The study by Madden et al (1976) highlights the
importance of staff managing these rules and restrictions consistently and in a fairly in order
to reduce the potentially aggressive outcomes that can result, and Meehan et al (2006)
reported that communication when dealing with such events as well as staff adhering to the
rules in place are important factors in maintaining an effective structure and reducing the
potential for conflict.
The role of training was a theme that was prominent throughout the literature. The City
model identifies specialist training as an underlying mechanism for reducing aggression. This
is supported in this review by the findings that, training increased staff ability to predict
aggression (Collins, 1994), staff perceived that more trained staff could prevent aggression
better (Chaimowitz and Moscovtich, 1991; Chen et al, 2007) and that training in aggression
management was related to those staff who perceived aggression as protective, thus
displaying an ability to understand aggression in a psychological way.

Although the role of staff characteristics is covered by the model in relation to skills and
competencies, other characteristics such as demography, physical characteristics and
personality are not addressed. Several studies reported that staff perceived personality to
influence aggression and physical attributes were mentioned in one study (Spokes et al,
2002). In relation to a number of themes staff experience is perceived as influencing
aggression. Although the City model acknowledges the role of experience in terms of
training, experience in terms of length of tenure as a modifying factor in its own right has
been missed.
The ward environment was a theme in the literature that was believed by staff and patients as
contributing to the occurrence of aggression. Environmental factors including a lack of
activities and being in a locked environment were reported to facilitate aggression in several
studies but the role of the ward or hospital environment has been missed by the City model.
8.9 Discussion
From the review of literature on staff and patient perceptions of aggression four higher level
themes were synthesised. These were the perception of aggression, causes of aggression,
preventing aggression and reactions to aggression.
The first theme, the perception of aggression, reports on the way in which the function of
psychiatric patient aggression is perceived by staff and the expectations that psychiatric staff
have about encountering aggression. Aggression was perceived as having both negative and
positive functions. A number of quantitative studies reported that staff variables such as
gender, psychiatric setting, staff experience and working pattern may influence the
perceptions staff have towards the function of aggression. The qualitative studies further
illustrated the individualistic nature of judgements about the function of aggression. The
findings that certain staff characteristics may influence staff perceptions of the function of
aggression may give scope for aiming interventions at certain staff groups in an attempt to
positively change their attitudes towards aggression. Understanding the way the nurses think
about the function of aggression has important implications for clinical practice. The way in
which nurses perceive aggression has important consequences for the way that incidents of
aggression are dealt with and reported. For example, if aggression is perceived as normal or
functional nurses may be less encouraged to intervene and to report these acts than if
aggression is perceived as violent behaviour (Jansen et al, 1997). Alder et al (1983) believe
that staffs general attitudes towards aggression are a key element in the management of
aggressive incidents.
Nurses expectations of encountering aggression were addressed in the expectation of
aggression subtheme. These studies overwhelmingly showed that nurses believe they will
be a victim of patient aggression during their careers, many nurses also felt that experiencing
aggression was to be expected as part of the nursing role. However, one study (Collins, 1994)
showed that through a training intervention, nurses expectation of being assaulted decreased.
By equipping nurses with more skills and confidence to deal with aggressive situations, they
felt more empowered and less expectant to be assaulted. This finding is interesting in terms of
interventions that can be used in practice to increase staff confidence in dealing with
aggression. This is even more important when considering an idea put forward by one of the
nurses in the study by Cutcliffe (1999) who suggested that nurses holding the expectation of
being assaulted could actually create the effect of a self fulfilling prophecy. Staff anxiety has
been found as a major contributor to aggression and violence in clinical areas (Madden et al,
1983) and Levy & Hartocollis (1976) reported that staff feelings of inadequacy concerning
their ability to handle a difficult situation with patients, when accompanied by frustration and
anger, may scare a disturbed patient to the point of driving them to violence. Interventions
could be targeted at helping nurses become more aware of the signals they give off when
dealing with patients who have the potential to become aggressive and learn skills in
managing their sensory outputs, such as voice, body language and posture, in such a way that
it reduces the likelihood of a patient becoming fearful and acting out.
The second theme to come out of the literature dealt with the causes of aggression. Patient
factors, staff factors, interaction, denying and restricting patients and environmental factors
were all identified by staff and patients as antecedents to aggression. The nature of the
patient group was described by both staff and patients as causing aggression. Staff believed
that symptoms of patient illness, especially psychotic symptoms were strong contributing
factors in aggressive acts by patients. Patients also described how they had difficulty in
controlling their behaviour when they became unwell. The intoxication of patients through
the use of drugs and alcohol was perceived to be another cause of aggression. Staff training in
attending to symptomatic displays, encouraging discussion between staff and patients about
how the patient is feeling, and limiting the ease of access to intoxicating substances are
strategies that could be employed by hospitals and staff which have the potential to reduce
aggression. In contrast to patient factors as antecedents of aggression, the second
subtheme reported on the role of staff factors. Several of the quantitative studies reported
that staff skills and competencies (or lack thereof) and staff personality can trigger aggressive
incidents. The qualitative studies allowed further exploration into the specific qualities that
may result in aggression. Staff perceptions of these factors included poor communication
skills, being inattentive, uncaring and rude. Tying in with this subtheme is the interaction
antecedent. This subtheme includes staff and patient perceptions of the interaction that takes
place on psychiatric units as a cause of aggression. These studies report that poor interactions
between staff and patients, including staff not listening adequately to patients, social
moments where there are groups of patients together and a lack of staff displayed empathy,
can cause aggression. Theses themes highlight the importance of the staff role in the
occurrence of aggression. Interventions aimed at reducing aggression on psychiatric wards
should focus on ways to improve and enhance interactions between staff and patients.
Increasing staff psychiatric philosophy to help them understand aggression in psychological
terms instead of blaming patients may serve to increase empathy, increasing staff interaction
skills through training in active listening and talking in a caring way may help to reduce the
perceptions that staff are rude, inattentive and uncaring. The denial and restriction of patient
behaviours including enforcing ward rules, refusing a request by a patient and limiting patient
behaviour, were described by thirteen studies as contributing to aggression. In addition,
patients described the way in which staff communicated restrictions and denials had the
potential to trigger aggression by patients. These studies highlight the importance of dealing
with patient requests and enforcing ward rules in a transparent and consistent way. Patients
described feeling frustrated when rules appeared too strict or when they felt they were being
ignored by staff. Staff should be encouraged to show patients that their requests have been
heard and give them a clear expectation of what will be done about the request and when. If
these requests are inappropriate or unrealistic then staff should be consistent and clear in their
explanations of why the request cannot be met or why the restrictions on behaviour are being
imposed. The way in which these matters are dealt with by staff has great potential to inflame
or dampen a potentially aggressive situation. Patients describe how staff take superior
attitudes or are brisk with patients, things that may seem trivial to staff might seem a much
more important issue to a patient, and this should be held in mind by staff.
The environment of the psychiatric ward was described by eleven studies as a factor
perceived as causing aggression by staff and patients. Specifically, overcrowding, lack of
facilities and activities, inadequate staffing and lack of access to outside space. Changing
structural aspects of the environment and increasing staff numbers is not easily achievable in
most inpatient situations. However, boredom was reported by patients as causing aggression,
and staff actions have the potential to lessen the patient experience of boredom. Staff can
ensure that there are activities available for patients to take part in on the ward, that scheduled
activities are not cancelled unless absolutely necessary, that they spend time with patients,
engaging and conversing with them, and increase opportunities for patients to go outside
when appropriate.
The third theme to come out of the literature was preventing aggression. Staff ability to
predict that an aggressive event will occur was the subject of the first subtheme. The majority
of staff believed that it is possible to predict that an aggressive event will occur. Noticing a
change in a patients behaviour was the most common way staff reported being able to
predict aggression. Other cues to aggression included times when there is increased activity
on the ward or overcrowding. If staff are able to foresee an aggressive event occurring then
they have an opportunity to stop it, or limit the fallout. Being aware of each patients
normal behaviour provides staff with the ability to notice when this starts to change. Good
communication between staff at handover of shift is important for information about a
patients behaviour to be passed on to staff coming onto shift. Staff skills in deescalating
situations are crucial at times when they feel a patient might start to become aggressive,
knowing a patient well, knowing what might calm them down or distract them are essential
for staff in successful de-escalation.
The second subtheme preventing aggression focused on the perceptions of staff about
factors that could prevent aggression from arising. Positively communicating, using
distraction techniques, taking precautionary measures before interacting with patients,
keeping the ward calm and safe and displaying a caring manner were ways in which staff
believed they could prevent patient aggression from occurring. In essence these are skills
staff can use to calm a patient down. Medication is also mentioned in these studies as a way
to prevent aggression from occurring. Although medication is often effective, by using the
staff skills described above, potentially aggressive situations may be able to be prevented
without turning to medication first. Staff training in the management of aggressive behaviour
is essential in preventing aggression from occurring or escalating. A high percentage of staff
in these studies did not believe they had received adequate training or training at an
appropriate time in their career to enable them to deal successfully with aggressive patients.
Specific training needs identified by staff included training in identifying potentially
aggressive situations, managing an aggressive situation, interpersonal skills and dealing with
volatile patients. Equipping staff with the specific skills they need to have the confidence and
skills to prevent and deal with aggression effectively should be at the forefront of clinical
aims for nurses in psychiatric settings.
The final theme in this review was the reaction to aggression. Most commonly staff victims
of aggression felt angered and fearful. Following assault several studies report that nurses had
difficulty in resuming their role of caring for the patients who were aggressive towards them.
As discussed earlier with regard to the self fulfilling prophecy idea of aggression, if staff are
fearful and angry towards patients they may exhibit behavioural cues which in turn put the
patient on edge, escalating situations and creating more conflict. Staff should use techniques
that allow them to control their own emotional reactions to situations so that none of these
emotional cues are leaked to patients. Staff should be encouraged to form relationships with
patients in order to gain a greater understanding of them and their behavioural motives. The
ability to understand the patient separately from their behaviour, being realistic in
expectations of the patient, understanding that there may be times when a patient needs to
express anger or vent emotions, and the ability to view aggression as a product of the
patients situation and diagnosis may reduce the staffs perceptions that an aggressive act is a
personal attack on them and reduce experienced anger and fear.
Conclusion
This review looked at quantitative and qualitative studies which explored both staff and
patient perceptions of aggression. By taking into consideration both types of methodologies
this review allowed a rich exploration of the perceptions of these groups. In many cases the
qualitative data allowed a deeper understanding of the findings presented by the numerical
findings of the quantitative studies which in turn added statistical validity to many of the
findings. Consideration of the views of both staff and patients gave an opportunity to explore
perception of aggression from both sides of the nurse patient relationship. Fundamental to
many of the themes presented in this review was the need for positive interaction between
staff and patients. Interaction and communication between staff and patients, if done
meaningfully and sincerely, can afford both groups better understanding of the behaviours,
reasons and attitudes of one another. Many of the causes of aggression and the skills used in
preventing and managing aggression were centred on communication and interaction.
Spending time with patients, communicating and interacting positively can foster a greater
understanding of patient needs, behaviours, motivations and individualities. Understanding
and appreciation of patients are important skills staff should work towards, having the
potential to make staff feel more positively about the function of patient aggression, reduce
aggression that is triggered by staff related factors, prevent aggression from occurring though
skills such as recognising changes in behavioural cues and, if and when aggression does
occur, being able to maintain understanding and positive appreciation of the patient which
can reduce the negative outcomes for both staff and patients.
9. REVIEW SUMMARY
This review included 424 empirical studies of inpatient violence and aggression, published in
English between 1960 and 2009. The findings are summarised below.
Incidence
Rates of violence and aggression could be calculated for 122 studies (30% of all those
included in the literature review). Rates varied markedly by country, setting, and settings
within countries. A higher proportion of forensic patients were violent and responsible for
more violent incidents. However, acute wards admitted many more patients (including
violent ones), and had higher rates per 100 occupied bed days. On balance, therefore, the risk
of violence was greater on acute wards. On average, nearly half of incidents involved
physical violence, and repeated incidents were common. The majority of nurses reported
experiencing violence at least once during their career, but rates for psychiatrists were much
lower.
Antecedents
The antecedents of violent and/or aggressive incidents were wide-ranging. Seventy-one

studies reported antecedent data, from which nine categories of antecedent were identified:
staff-patient interaction, patient behavioural cues (agitation, attention-seeking behaviour,
increased motor activity, boisterousness, and confusion), no clear cause, patient symptoms,
patient-patient interaction, patient conflict behaviours, structural issues, patient emotional/
mood cues and external/personal issues. However, most studies reported antecedent data
exclusively from the perspective of staff, while only five papers captured the patients
perspective. The data also suggest that a third of incidents are either unprovoked (which is
unlikely), staff are failing to recognise antecedents, or staff are recognising antecedents but
are not recording them. The true breadth and scope of antecedents of violence and aggression
therefore remains uncertain.
Consequences
There were eight categories of consequences identified from 108 studies. These ranged from
the nature and severity of physical injuries, use of containment (such as seclusion, medication
or restraint), patient transfers/discharges, psychological and behavioural outcomes for the
victims, and damage to property/objects. Again, the data overwhelming reflected staff reports
of consequences, with a tendency to focus on injuries experienced by the staff victims of the
assault. Overall, an injury is likely to occur in a third of violent/aggressive incidents that a
staff member is involved in. Violent incidents within acute settings were 20% more likely to
result in staff injury compared to forensic settings.
Patient profile
Sixty-three studies compared aggressive and non-aggressive patients. Meta analyses

identified several patient factors associated with violence and aggression. Patients with a
diagnosis of schizophrenia were more likely to be violent than patients with other diagnoses.
Patients were also more likely to be violent if they were young, male, single, from an ethnic
minority, and admitted a compulsory/formal admission.
Time and place
Evidence from 78 studies found no consistent seasonal effects, but peaks in violence by time
of day corresponded with specific events and activities on the wards (e.g. waking, medication
rounds and meal-times). Weekends were usually quieter because of reduced association
between patients and staff. Incidents occur in most areas of the ward, but particularly in
corridors, bedrooms, lounge areas and around nursing stations.
Patient and staff perspectives
Sixty papers included data on staff and patient attitudes, perceptions and motivations of
violence and aggression (38 staff, 9 patient and 13 both). These were organised into four
themes: the perception of aggression, causes of aggression, preventing aggression and
reactions to aggression. Aggression was perceived as having both negative and positive
functions, and varied by staff variables such as gender, setting, experience and working
pattern. Staff firmly believe they will be a victim of patient aggression at some point during
their career, with may reporting that experiencing aggression was to be expected as part of
the nursing role. Patient factors (especially psychotic symptoms), staff factors (e.g. lack of
skills), denying and restricting patients and environmental factors (overcrowding, lack of
facilities and activities, inadequate staffing and lack of access to outside space) were all
identified by staff and patients as reasons for aggression. Most staff believed it possible to
predict aggressive events before, usually by noticing a change in a patients behaviour.
10. Acknowledgement
This report presents independent research commissioned by the National Institute for Health
Research (NIHR) under its Programme Grants for Applied Research scheme (RP-PG-0707-
10081) and supported by the NIHR Mental Health Research Network. The views expressed
are those of the authors and not necessarily those of the NHS, the NIHR or the Department of
Health.
11. REFERENCES
Studies included in the review
Abbott, A. 1978, "Accident and its correlates in a psychiatric hospital", Acta Psychiatrica
Scandinavica, vol. 57, no. 1, pp. 36-48.
Abderbalden, C., Needham I., Friedli, T., Poelmans, J., & Dassen, T. 2002, "Perception of
aggression among psychiatric nurses in Switzerland", Acta Psychiatr Scand, vol. 106, no.
Suppl 412, pp. 110-117.
Abderhalden, C., Needham, I., Dassen, T., Halfens, R., Fischer, J. E., & Haug, H.-J. 2007,
"Frequency and severity of aggressive incidents in acute psychiatric wards in Switzerland",
Clinical Practice & Epidemiology in Mental Health, vol. 30.
Abderhalden, C., Needham, I., Dassen, T., Halfens, R., Haug, H. J., & Fischer, J. E. 2008,
"Structured risk assessment and violence in acute psychiatric wards: randomised controlled
trial", British Journal of Psychiatry, 193, pp. 44-50.
Abeyasinghe, R. & Jayasekera, R. 2003, "Violence in a general hospital psychiatry unit for
men", Ceylon Medical Journal, vol. 48, pp. 45-47.
Abushua'leh, K. & bu-Akel, A. 2006, "Association of psychopathic traits and

symptomatology with violence in patients with schizophrenia", Psychiatry Research no. 2-3,
pp. 205-211.
Adams, J. & Whittington, R. 1995, "Verbal aggression to psychiatric staff: traumatic stressor
or part of the job?", Perspectives in Psychiatric Care, vol. 2, no. 2, pp. 171-174.
Agarwal, M. & Roberts, M. 1996, "Violence among psychiatric inpatients at an Interim

Secure Unit: changes in pattern over a two-year period.", Medicine, Science and the Law, vol.
36, no. 1, pp. 31-36.
Agervold, M. & Andersen, L. P. 2006, "Incidence and impact of violence against staff on
their perceptions of the psychosocial work environment", Nordic Psychology, vol. 58, no. 3,
pp. 232-247.
Aiken, G. J. M. 1984, "Assaults on staff in a locked ward: Prediction and Consequences",

Medicine, Science and the Law, vol. 24, no. 3, pp. 199-207.
Alder, W., Kreeger, C., & Ziegler, P. 1983, "Patient violence in private psychiatric wards," in
Assaults within psychiatric facilities, R. Lion & W. Reid, eds., Grune & Stratton, New York.
Almvik, R. & Woods, P. 1998, "The Broset Violence Checklist (BVC) and the prediction of
inpatient violence: Some preliminary results.", Psychiatric Care, vol. 5, no. 6, pp. 208-211.
Arango, C., Barba, A. C., Gonzalez-Salvador, T., & Ordonez, A. C. 1999, "Violence in
Inpatients With Schizophrenia: A Prospective Study", Schizophrenia Bulletin, vol. 25, no. 3,
pp. 493-503.
Arnetz, J. & Arnetz, B. 2000, "Implementation and evaluation of a practical intervention
programme for dealing with violence towards health care workers", Journal of Advanced
Nursing, vol. 31, no. 3, pp. 668-680.
Augestad, L. B. & Vatten, L. V. 1994, "Five year risk of assault on employees in a

psychiatric hospital", Safety Science, vol. 18, pp. 113-124.
Barlow, K., Grenyer, B., & Ilkiw-Lavalle, O. 2000, "Prevalence and precipitants of
aggression in psychiatric inpatient units", Australian and New Zealand Journal of Psychiatry,
vol. 34, pp. 967-974.
Baxter, E., Hafner, R. J., & Holme, G. 1992, "Assaults by patients: the experience and
attitudes of psychiatric hospital nurses", Australian & New Zealand Journal of Psychiatry.,
vol. 26, no. 4, pp. 567-573.
Beauford, J. E., Dale, E., McNiel, E., & Binder, R. L. 1997, "Utility of the Initial Therapeutic
Alliance in Evaluating Psychiatric patients' Risk of Violence", American Journal of
Psychiatry, vol. 154:1272-1276.
Benjaminsen, S., GotzscheLarsen, K., Norrie, B., Harder, L., & Luxhoi, A. 1996, "Patient
violence in a psychiatric hospital in Denmark. Rate of violence and relation to diagnosis",
Nordic Journal of Psychiatry., vol. 50, no. 3, pp. 233-242.
Bensley, L., Nelson, N., Kaufman, J., Silverstein, B., & Shields, J. W. 1995, "Patient and
staff views of factors influencing assaults on psychiatric hospital employees", Issues in
Mental Health Nursing, vol. 16, no. 5, pp. 433-446.
Bensley, L., Nelson, N., Kaufman, J., Silverstein, B., Kalat, J., & Shields, J. W. 1997,
"Injuries due to assaults on psychiatric hospital employees in Washington State", American
Journal of Industrial Medicine., vol. 31, no. 1, pp. 92-99.
Bilgin, H. & Buzlu, S. 2006, "A study of psychiatric nurses' beliefs and attitudes about work
safety and assaults in Turkey", Issues in Mental Health Nursing, vol. 27, pp. 75-90.
Binder, R. L. & McNiel, D. E. 1990, "The relationship of Gender to violent behavior in

Acutely Disturbed Psychiatric Patients", Journal of Clinical Psychiatry, vol. 51(3): pp110-
114.
Binder, R. L. & McNiel, D. E. 1994, "Staff gender and risk of assault on doctors and nurses",
Bulletin of the American Academy of Psychiatry & the Law, vol. 22, no. 4, pp. 545-550.
Bisconer, S. W., Green, M., Mallon-Czajka, J., & Johnson, J. S. 2006, "Managing aggression
in a psychiatric hospital using a behaviour plan: a case study", Journal of Psychiatric and
Mental Health Nursing, vol. 13, pp. 515-521.
Bjorkdahl, A., Heilig, M., Palmstierna, T., & Hansebo, G. 2007, "Changes in the occurrences
of coercive interventions and staff injuries on a psychiatric intensive care unit", Archives of
Psychiatric Nursing , vol. 21, no. 5, pp. 270-277.
Blomhoff, S., Seim, S., & Friis, S. 1990, "Can prediction of violence among psychiatric
inpatients be improved", Hospital and Community Psychiatry, vol. 41: 771-775.
Blow, F., Barry, K., Copeland, L., McCormick, R., Lehmann, L., & Ullman, E. 1999,
"Repeated assaults by patients in VA hospital and clinical settings", Psychiatric Services, vol.
50, pp. 390-394.
Bond, K. & Brimblecombe, N. 2004, "Violent Incidents and Staff Views", Mental Health
Nursing, vol. 23, no. 6, pp. 10-12 (cont on 17).
Bouras, N., Trauer, T., Rosen, B., & et al 1981, "Temporal patterns in ward disturbances
among psychiatric patients", British Journal of Clinical Psychology, vol. 20, pp. 139-140.
Bouras, N., Trauer, T., & Watson, J. P. 1982, "Ward environment and disturbed behaviour",
Psychological Medicine, vol. 12, pp. 309-319.
Brizer, D. A., Crowner, M. L., Convit, A., & Volavka, J. 1988, "Videotape Recording of
Inpatient Assaults: A Pilot Study", American Journal of Psychiatry, vol. 145:6, p751-752.
Brock, G., Gurekas, V., Gelinas, A. F., & Rollin, K. 2009, "Use of a "secure room" and a
security guard in the management of the violent, aggressive or suicidal patient in a rural
hospital: a 3-year audit", Canadian Journal of Rural Medicine, vol. 14, no. 1, pp. 16-20.
Calabro, K., Mackey, T., & Williams, S. 2002, "Evaluation of training designed to prevent
and manage patient violence", Issues in Mental Health Nursing, vol. 23, pp. 3-15.
Caldwell, M. 1992, "The incidence of PTSD among staff victims of patient violence",
Hospital and Community Psychiatry, vol. 43, pp. 838-839.
Carmel, H., Tanke, E., & Yesavage, J. 1991, "Physican staffing and patient violence",
Bulletin of the Academy of Psychiatry and the Law, vol. 19, p. 1.
Carmel, H. & Hunter, M. 1989, "Staff injuries from inpatient violence", Hospital and
Community Psychiatry, vol. 40(1): 41-46.
Carmel, H. & Hunter, M. 1993, "Staff injuries from patient attack: five years' data", Bulletin
of the American Academy of Psychiatry & the Law, vol. 21, no. 4, pp. 485-493.
Carmel, H. & Hunter, M. 1991, "Psychiatrists injured by patient attack", Bulletin of the
American Academy of Psychiatry and law , vol. 19, pp. 309-316.
Carmel, M. D. & Hunter, M. 1990, "Compliance with training in managing assaultive

behaviour and injuries from inpatient violence", Hospital and Community Psychiatry, vol.
41(5): 558-560.
Carr, V. J., Lewin, T. J., Sly, K. A., Conrad, A. M., Tirupati, S., Cohen, M., Ward, P. B., &
Coombs, T. 2008, "Adverse incidents in acute psychiatric inpatient units: rates, correlates and
pressures", Australian & New Zealand Journal of Psychiatry, vol. 42, no. 4, pp. 267-282.
Carton, G. & et al. 2003, "Reducing Violence in a Special Hospital", Nursing Standard, vol.
17, no. 5, pp. 29-31.
Casseem, M. 1984, "Violence on the Wards", Nursing Mirror, vol. 158, pp. 14-16.
Chaimowitz, G. A. & Moscovitch, A. 1991, "Patient assaults on psychiatric residents: the
Canadian experience", Canadian Journal of Psychiatry, vol. 36, no. 2, pp. 107-111.
Chaplin, R., McGeorge, M., & Lelliott, P. 2006, "The National Audit of Violence: In-patient
care for adults of working age", Psychiatric Bulletin, vol. 30, no. 12, pp. 444-446.
Chaplin, R., McGeorge, M., & Lelliott, P. 2006, "Violence on inpatient units for people with
learning disability and mental illness: the experiences of service users and staff", British
Journal of Developmental Disabilities, vol. 52 part 2, no. 103, pp. 105-115.
Chaplin, R., McGeorge, M., Hinchcliffe, G., & Shinkwin, L. 2008, "Aggression on
psychiatric inpatient units for older adults and adults of working age", International Journal
of Geriatric Psychiatry, vol. 23, no. 8, pp. 874-876.
Chen, S., Hwu, H., & Williams, R. 2005, "Psychiatric nurses' anxiety and cognition in
managing psychaitric patients' aggression", Archives of Psychiatric Nursing, vol. 19, no. 3,
pp. 141-149.
Chen, W. C., Wang, J. D., Lew-Ting, C. Y., Chiu, H. J., & Lin, Y. P. 2007, "Workplace
violence on workers caring for long-term institutionalized schizophrenic patients in Taiwan",
Journal of Occupational Health, vol. 49, no. 4, pp. 311-316.
Chen, W. C., Hwu, H. G., Kung, S. M., Chiu, H. J., & Wang, J. D. 2008, "Prevalence and
determinants of workplace violence of health care workers in a psychiatric hospital in
Taiwan", Journal of Occupational Health, vol. 50, no. 3, pp. 288-293.
Chen, W. C., Hwu, H. G., & Wang, J. D. 2009, "Hospital staff responses to workplace
violence in a psychiatric hospital in Taiwan", International Journal of Occupational &
Environmental Health, vol. 15, no. 2, pp. 173-179.
Cheung, P., Schweitzer, I., Tuckwell, V., & Crowley, K. C. 1996, "A Prospective Study of
Aggression Among Psychiatric Patients in Rehabilitation Wards", Australian and New
Zealand Journal of Psychiatry, vol. 30, pp. 257-262.
Cheung, P., Schweitzer, I., Tuckwell, V., & Crowley, K. C. 1997, "A prospective study of
assaults on staff by psychiatric in-patients", Medicine, Science & the Law, vol. 37, no. 1, pp.
46-52.
Cheung, P., Schweitzer, I., Crowley, K., & Tuckwell, V. 1997, "Violence in schizophrenia:
role of hallucinations and delusions.", Schizophrenia Research, vol. 26, pp. 181-190.
Cheung, P., Schweitzer, I., Crowley, K., & Tuckwell, V. 1997, "Aggressive behaviour in
schizophrenia: the role of psychopathology.", Australian & New Zealand Journal of
Psychiatry, vol. 31, pp. 62-67.
Chou, K. R., Lu, R. B., & Mao, W. C. 2002, "Factors relevant to patient assaultive behavior
and assault in acute inpatient psychiatric units in Taiwan. [References]", Archives of
Psychiatric Nursing., vol. 16, no. 4, pp. 187-195.
Chou, K., Lu, R., & Chang, M. 2001, "Assaultive Behavior by Psychiatric In-Patients and Its
Related Factors", Journal of Nursing Research, vol. 9, no. 5, pp. 139-151.
Chukwujekwu, D. C. & Stanley, P. C. 2008, "The Modified Overt Aggression Scale: how
valid in this environment?", Nigerian Journal of Medicine: Journal of the National
Association of Resident Doctors of Nigeria.17(2):153-5, vol. 17, no. 2, pp. 153-155.
Coldwell, J. & Naismith, L. 1989, "Violent incidents on special care wards in a special
hospital", Medicine, Science and the Law, vol. 29, pp. 116-123.
Cole, A. 2005, "Four in five nurses on mental wards face violence", British Medcial Journal,
vol. 330, no. 7502, p. 1227.
Collins, J. 1994, "Nurses' attitudes towards aggressive behaviour, following attendance at

'The Prevention and Management of Aggressive Behaviour Programme'", Journal of
Advanced Nursing, vol. 20, pp. 117-131.
Conn, L. & Lion, J. 1983, "Assaults in a university hospital," in Assualts Within a Psychiatric
Facilities, J. Lion, ed., Grune & Stratton, New York, pp. 61-69.
Convey, J. 1986, "A Record of Violence", Nursing Times, vol. 82, no. 46, pp. 36-38.
Convit, A., Isay, D., Gadioma, R., & et al 1988, "Underreporting of physical assaults in
schizophrenic inpatients", Journal of Nervous and Mental Disease, vol. 176, pp. 507-509.
Convit, A., Jaeger, J., Pin Lin, S., Meisner, M., & Volavka, J. 1988, "Predicting
Assaultiveness in psychiatric inpatients: a pilot study", Hospital and Community Psychiatry,
vol. 39, no. 4, pp. 429-434.
Convit, A., Isay, D., Otis, D., & Volavka, J. 1990, "Characteristics of repeatedly assaultive
psychiatric inpatients", Hospital & Community Psychiatry., vol. 41, no. 10, pp. 1112-1115.
Cooper, A. & Medonca, J. 1991, "A prospective study of patient assaults on nurses in a
provincial psychiatric hospital in Canada", Acta Psychiatrica Scandinavica, vol. 84, pp. 163-
166.
Cooper, S. J., Brown, F. W. A., McLean, K. J., & King, D. J. 1983, "Aggressive behaviour in
a psychiatric observation ward", Acta Psychiatrica Scandinavica, vol. 68(386-393).
Crichton, J., Callanan, T., Beauchamp, L., Giasson, M., & Tardiff, H. 1998, " Staff response
to psychiatric inpatient violence: an international comparison", Psychiatric Care, vol. 5, no.
2, pp. 50-56.
Crichton, J. H. M. & Calgie, J. 2002, "Responding to Inpatient Violence at a Psychiatric

Hospital of Special Security: A Pilot Project", Medicine, Science and the Law, vol. 42, no. 1,
pp. 30-33.
Crowner, M., Peric, G., Stepcic, F., & Ventura, F. 1995, "Psychiatric Patients' Explanations
for Assaults", Psychiatric Services, vol. 46, no. 6, pp. 614-615.
Crowner, M. C., Douyon, R., Convit, A., & Volavka, J. 1991, "Videotape Recording of
Assaults on a State Hospital Inpatient Ward", Journal of Neuropsychiatry, vol. 3, no. 2, pp.
59-64.
Crowner, M. L., Peric, G., Stepcic, F., & Van Oss, E. 1994, "A comparison of videocameras
and official incident reports in detecting inpatient assaults", Hospital and Community
Psychiatry, vol. 45: 11 1144-1145.
Crowner, M. L., Peric, G., Stepcic, F., & Lee, S. 2005, "Assailant and victim behaviors
immediately preceding inpatient assault", Psychiatric Quarterly, vol. 76, no. 3, pp. 243-256.
Currid, T. J. 2008, "The lived experience and meaning of stress in acute mental health
nurses", British Journal of Nursing, vol. 17, no. 14, pp. 880-884.
Cutcliffe, J. 1999, "Qualified nurses' lived experience of violence perpetuated by individuals

suffering from enduring mental health problems", International Journal of Nursing Studies,
vol. 36, pp. 105-116.
Daffern, M., Mayer, M. M., & Martin, T. 2003, "A preliminary investigation into patterns of
aggression in Australian forensic psychiatric hospital", The Journal of Forensic Psychiatry &
Psychology, vol. 14, no. 1, pp. 67-84.
Daffern, M. & Howells, K. 2007, "Aggressive Behaviour in High-Risk Personality

Disordered Inpatients During Prison and Following Admission to Hospital", Psychiatry
Psychology & Law, vol. 14, no. 1, pp. 26-34.
Daffern, M., Howells, K., Ogloff, J., & Lee, J. 2005, "Individual characteristics predisposing
patients to aggression in a forensic psychiatric hospital", Journal of Forensic Psychiatry &
Daffern, M., Mayer, M., & Martin, T. 2006, "Staff gender ratio and aggression in a forensic
psychiatric hospital", International Journal of Mental Health Nursing, vol. 15, pp. 93-99.
Daffern, M., Howells, K., & Ogloff, J. 2007, "The interaction between individual
characteristics and the function of aggression in forensic psychiatric inpatients", Psychiatry
Psychology & Law, vol. 14, no. 1, pp. 17-25.
Daffern, M. & Howells, K. 2009, "The function of aggression in personality disordered

patients", Journal of Interpersonal Violence, vol. 24, no. 4, pp. 586-600.
Daffern, M., Ogloff, J., & Howells, K. 2003, "Aggression in an Australian forensic
psychiatric hospital.", British Journal of Forensic Practice., vol. 5, no. 4, pp. 18-28.
Daffern, M., Mayer, M. M., & Martin, T. 2004, "Environment contributors to aggression in
two forensic psychiatric hospitals.", International Journal of Forensic Mental Health., vol. 3,
no. 1, pp. 105-114.
Daffern, M., Ogloff, J. R. P., Ferguson, M., & Thomson, L. 2005, "Assessing risk for
aggression in a forensic psychiatric hospital using the Level of Service Inventory-Revised:
Screening Version", International Journal of Forensic Mental Health, vol. 4, no. 2, pp. 201-
206.
Daffern, M., Ferguson, M., Ogloff, J., Thomson, L., & Howells, K. 2007, "Appropriate
treatment targets or products of a demanding environment? The relationship between
aggression in a forensic psychiatric hospital with aggressive behaviour preceding admission
and violent recidivism", Psychology, Crime & Law, vol. 13, no. 5, pp. 431-441.
Daffern, M., Duggan, C., Huband, N., & Thomas, S. 2008, "The impact of interpersonal style
on aggression and treatment non-completion in patients with personality disorder admitted to
a medium secure psychiatric unit", Psychology, Crime & Law, vol. 14, no. 6, pp. 481-492.
Daffern, M., Howells, K., Stacey, J., Hogue, T., & Mooney, P. 2008, "Is sexually abusive
behaviour in personality disordered inpatients analogous to sexual offences committed prior
to hospitalization?", Journal of Sexual Aggression, vol. 14, no. 2, pp. 123-133.
Dawson, J., Johnson, M., Kehiayan, N., & et al 1988, "Response to patient assault: a peer
support program for nurses", Journal of Psychosocial Nursing and Mental Health Services,
vol. 26, pp. 8-15.
De Neit, G. J., Hutschemaekers, J. M., & Lendemeijer, B. H. H. G. 2005, "Is the reducing
effect of the Staff Observation Aggression Scale owing to a learning effect? An explorative
study", Journal of Psychiatric and Mental Health Nursing, vol. 12, pp. 687-694.
de Vogel, V. & de Ruiter, C. 2006, "Structured professional judgment of violence risk in

forensic clinical practice: A prospective study into the predictive validity of the Dutch HCR-
20", Psychology, Crime & Law, vol. 12, no. 3, pp. 321-336.
Decaire, M. W., Bedard, M., Riendeau, J., & Forrest, R. 2006, "Incidents in a psychiatric
forensic setting: association with patient and staff characteristics", Canadian Journal of
Nursing Research, vol. 38, no. 3, pp. 68-80.
Delaney, J., Cleary, M., Jordan, R., & Horsfall, J. 2001, "An exploratory investigation into
nursing management of aggression in acute psychiatric settings", Journal of Psychiatric and
Delaney, K. R. & Johnson, M. E. 2006, "Keeping the unit safe: mapping psychiatric nursing
skills", Journal of the American Psychiatric Nurses Association, vol. 12, no. 4, pp. 198-207.
Depp, F. 1983, "Assaults in a Public Mental Hospital", in Lion, J.and Reid, W.(Eds) Assaults
Within psychiatric Facilities.Orlando: Grune and Stratton., vol. 21-45.
Depp, F. C. 1976, "Violent behaviour patterns on psychiatric wards", Aggressive Behaviour,

vol. 2, pp. 299-306.
Dernevik, M., Grann, M., & Johansson, S. 2002, "Violent behavior in forensic psychiatric
patients: Risk assessment and different risk-management levels using the HCR-20.",
Psychology, Crime & Law, vol. 8, pp. 93-111.
Dibben, C., O'Shea, R., Chang, R., & Woodger, J. 2008, "Safety for psychiatrists--From
trainee to consultant", Psychiatric Bulletin, vol. 32, no. 3, pp. 85-87.
Dietz, P. E. & Rada, R. T. 1982, "Battery Incidents and Batterers in a Maximum Security
Hospital", Archives of General Psychiatry, vol. 39:31-34.
Dinakar, H. S. & Sobel, R. N. 2001, "Violence in the community as a predictor of violence in

the hospital", Psychiatric Services, vol. 52, no. 2, pp. 240-241.
Dolan, M. & Fullam, R. 2007, "The validity of the Violence Risk Scale second edition (VRS-
2) in a British forensic inpatient sample", Journal of Forensic Psychiatry &
Psychology.Vol.18(3)()(pp 381-393), 2007. no. 3, pp. 381-393.
Dolan, M., Fullam, R., Logan, C., & Davies, G. 2008, "The Violence Risk Scale Second
Edition (VRS-2) as a predictor of institutional violence in a British forensic inpatient
sample", Psychiatry Research, vol. 158, no. 1, pp. 55-56.
Dooley, E. 1986, "Aggressive incidents in a secure hospital", Medicine, Science and the Law,
vol. 26, pp. 125-130.
Dowson, J. H., Butler, J., & Williams, O. 1999, "Management of psychiatric in-patient
violence in the Anglia region. Implications for record-keeping, staff training and victim
support", Psychiatric Bulletin. , vol. 23, no. 8, pp. 486-489.
Doyle, M. 2002, "The validity of North American risk assessment tools in predicting
inpatient violent behaviour in England", Legal and Criminological Psychology, vol. 7, pp.
141-154.
Doyle, M. & Dolan, M. 2006, "Evaluating the Validity of Anger Regulation Problems,
Interpersonal style, and Disturbed Mental state for Predicting Inpatient Violence", Behavioral
Sciences and the Law, vol. 24, pp. 783-798.
Duxbury J., Hahn, S., Needham I., & Pulsford, D. 2008, "The Management of Aggression
and Violence Attitude Scale (MAVAS): a cross-national comparative study.", Journal of
Advanced Nursing, vol. 62, no. 5, pp. 596-606.
Duxbury, J. & Whittington, R. 2005, "Causes and management of patient aggression and
violence: staff and patient perspectives", Journal of Advanced Nursing, vol. 50, no. 5, pp.
469-478.
Edwards, J., Jones, D., Reid, W., & et al 1988, "Physical assaults in a psychiatric unit of a
general hospital", American Journal of Psychiatry, vol. 145, pp. 1568-1571.
Ehmann, T. S., Smith, G. N., Yamamoto, A., McCarthy, N., Ross, D., Au, T., Flynn, S. W.,
Altman, S., & Honer, W. G. 2001, "Violence in treatment resistant psychotic inpatients",
Journal of Nervous & Mental Disease., vol. 189, no. 10, pp. 716-721.
El-Badri, S. M. & Mellsop, G. 2006, "Aggressive behaviour in an acute general adult

psychiatric unit", Psychiatric Bulletin no. 5, pp. 166-168.
Elbogen, E. B., Williams, A. L., Kim, D., Tomkins, A. J., & Scalora, M. J. 2001, "Gender
and perceptions of dangerousness in civil psychiatric patients", Legal and Criminological
Psychology, vol. 6, pp. 215-228.
Emmerson, B., Fawcett, L., Ward, W., Catts, S., Ng, A., & Frost, A. 2007, "Contemporary
management of aggression in an inner city mental health service", Australasian Psychiatry,
vol. 15, no. 2, pp. 115-119.
Evenson, R. C., Sletten, I. W., Altman, H., & Brown, M. L. 1974, "Disturbing Behavior: A
Sudy of Incident Reports", Psychiatric Quarterly., vol. 48, no. 2, pp. 266-275.
Evershed, S., Tennant, A., Boomer, D., Rees, A., Barkham, M., & Watson, B. 2003,
"Practice-based outcomes of dialectical behavior therapy (DBT) targeting anger and violence,
with male forensic patients: a pragmatic and non-contemporaneous comparison.", Criminal
Behaviour & Mental Health , vol. 13, pp. 198-213.
Fagan-Pryor, E. C., Haber, L. C., Dunlap, D., Nall, J. L., Stanley, G., & Wolpert, R. 2003,
"Patients' views of causes of aggression by patients and effective interventions", Psychiatric
Services., vol. 54, no. 4, pp. 549-553.
Fairlie, A. & Brown, R. 1994, "Accidents and incidents involving patients in a mental health
service", Journal of Advanced Nursing, vol. 19, no. 5, pp. 864-869.
Farrell, G. 1999, "Aggression in clinical settings: Nurses' views-A follow-up study", Journal
of Advanced Nursing, vol. 29, pp. 532-541.
Farrell, G. A., Bobrowski, C., & Bobrowski, P. 2006, "Scoping workplace aggression in
nursing: findings from an Australian Study", Journal of Advanced Nursing, vol. 55, no. 6, pp.
778-787.
Ferguson, C. J., Averill, P. M., Rhoades, H., Rocha, D., Gruber, N. P., & Gummattira, P.
2005, "Social Isolation, Impulsivity and Depression as Predictors of Aggression in a
Psychiatric Inpatient Population.", Psychiatric Quarterly, vol. 76, no. 2, pp. 123-137.
Ferns, T. & Meerabeau, L. 2008, "Verbal Abuse Experienced by Nursing Students", Journal
of Advanced Nursing, vol. 61, no. 4, pp. 436-444.
Finnema, E. J., Dassen, T., & Halfens, R. 1994, "Aggression in Psychiatry: a Qualitative
Study Focussing on the Characterisation and perception of Patient Agression by Nurses
Working on Psychiatric Wards", Journal of Advanced Nursing, vol. 19:1088-1095.
Flannery Jr, R. B., Hanson, M., Penk, W., & Flannery, G. J. 1994, "Violence against women:
Psychiatric patient assaults on female staff", Professional Psychology Research and
Practice, vol. 25, no. 2, pp. 182-184.
Flannery, R., Fulton, P., Tausch, J., & et al 1991, "A program to help staff cope with
psychological sequelae of assaults by patients", Hospital and Community Psychiatry, vol. 42,
pp. 935-938.
Flannery, R. & Penk, W. 1993, "Cyclical variaitons in psychiatric patients-to-staff assaults:

preliminary enquiry", Psychological Reports, vol. 72, p. 642.
Flannery, R., Hanson, M. A., Penk, W., Goldfinger, S., Pastva, G., & Navon, M. 1998,
"Replicated declines in assault rates after implementation of the assaulted staff action
program", Psychiatric Services, vol. 49, pp. 241-243.
Flannery, R., Schuler, A., Farley, E., & Walker, A. 2002, "Characteristics of assaultive
psychiatric patients: ten year analysis of the Assaulted Staff Action Program (ASAP)",
Psychiatric Quarterly, vol. 73, pp. 59-69.
Flannery, R., Rachlin, S., & Walker, A. 2002, "Characteristics of repetitively assaultive
patients: Ten year analysis of the Assaulted Staff Action Program (ASAP)", International
Journal of Emergency Mental Health, vol. 4, no. 3, pp. 173-179.
Flannery, R., Rachlin, S., & Walker, A. 2002, "Characteristics of assaultive patients with
schizophrenia versus personaility disorder:Six year analysis of the Assaulted Staff Action
Program (ASAP)", Journal of Forensic Sciences, vol. 47, no. 3, pp. 558-561.
Flannery, R. B., Jr., Hanson, M. A., & Penk, W. 1995, "Patients' threats. Expanded definition
of assault", General Hospital Psychiatry., vol. 17, no. 6, pp. 451-453.
Flannery, R. B., Jr., Hanson, M. A., Penk, W. E., & Flannery, G. J. 1996, "Violence and the
lax milieu?: preliminary data", Psychiatric Quarterly., vol. 67, no. 1, pp. 47-50.
Flannery, R. B., Jr., Hanson, M. A., Penk, W. E., Pastva, G. J., Navon, M. A., & Flannery, G.
J. 1997, "Hospital downsizing and patients' assaults on staff", Psychiatric Quarterly, vol. 68,
no. 1, pp. 67-76.
Flannery, R. B., Jr., Penk, W. E., Irvin, E. A., & Gallagher, C. 1998, "Characteristics of
violent versus nonviolent patients with schizophrenia", Psychiatric Quarterly., vol. 69, no. 2,
pp. 83-93.
Flannery, R. B., Jr., Irvin, E. A., & Penk, W. E. 1999, "Characteristics of assaultive
psychiatric inpatients in an era of managed care", Psychiatric Quarterly., vol. 70, no. 3, pp.
247-256.
Flannery, R. B., Jr., Corrigan, M., Tierney, T., & Walker, A. P. 2000, "Time and risk of
psychiatric patient assault: Ten year analysis of the ASAP.", Journal of healthcare safety,
compliance and infection control, vol. 5, pp. 31-35.
Flannery, R. B., Jr., Hanson, M. A., & Rego, J. J. &. W. A. P. 2003, "Precipitants of
psychiatric patient assault on staff: Preliminary empirical inquiry of the Assaulted Staff
Action Program (ASAP)", International Journal of Emergency Mental Health, vol. 5, pp.
141-146.
Flannery, R. B., Jr., Juliano, J., Cronin, S., & Walker, A. P. 2006, "Characteristics of
assaultive psychiatric patients: fifteen-year analysis of the Assaulted Staff Action Program
(ASAP)", Psychiatric Quarterly, vol. 77, no. 3, pp. 239-249.
Flannery, R. B., Jr., Farley, E., Rego, S., & Walker, A. P. 2007, "Characteristics of staff
victims of pschiatric patient assaults: 15-year analysis of the Assaulted Staff Action Program
Flannery, R. B., Jr., Marks, L., Laudani, L., & Walker, A. P. 2007, "Psychiatric patient
assault and staff victim gender: fifteen-year analysis of the Assaulted Staff Action Program
Flannery, R. B., Jr. & Walker, A. P. 2008, "Characteristics of four types of patient assaults:
fifteen-year analysis of the Assaulted Staff Action Program (ASAP) with EMS implications",
International Journal of Emergency Mental Health., vol. 10, no. 3, pp. 177-184.
Flannery, R. B., Jr. & Walker, A. P. 2008, "Repetitively assaultive psychiatric patients:
fifteen-year analysis of the Assaulted Staff Action Program (ASAP) with implications for
emergency services", International Journal of Emergency Mental Health, vol. 10, no. 1, pp.
1-8.
Flannery, R. B. J. & Walker, A. P. 2001, "Characteristics of four types of patient assaults: Six
year analysis of the Assaulted Staff Action Program (ASAP). [References]", International
Journal of Emergency Mental Health., vol. 3, no. 4, pp. 211-216.
Flannery, R. B. J., Laudani, L., Levitre, V., & Walker, A. P. 2006, "Precipitants of
psychiatric patient assaults on staff: Three-year empirical inquiry of the assaulted staff action
program (ASAP)", International Journal of Emergency Mental Health, vol. 8, no. 1, pp. 15-
22.
Flannery, R. B. J., White, D. L., Flannery, G. J., & Walker, A. P. 2007, "Time of psychiatric
patient assaults: Fifteen-year analysis of the Assaulted Staff Action Program (ASAP)",
International Journal of Emergency Mental Health, vol. 9, no. 2, pp. 89-96.
Flood, C., Bowers, L., & Parkin, D. 2008, "Estimating the costs of conflict and containment
on adult acute inpatient psychiatric wards.", Nursing Economics, vol. 26, no. 5, pp. 325-330.
Foster, C., Bowers, L., & Nijman, H. 2007, "Aggressive behaviour on acute psychiatric
wards: prevalence, severity and management", Journal of Advanced Nursing, vol. 58, no. 2,
pp. 140-149.
Fottrell, E., Bewley, T., & Sqizzoni, M. 1978, "A Study of Aggressive and Violent Behaviour
Among a Group of psychiatric In Patients", Medicine, Science and the Law, vol. 18, no. 1,
pp. 66-69.
Fottrell, E. 1980, "A Study of Violent behaviour Among patients in psychiatric Hospitals",
British Journal of Psychiatry, vol. 136, pp. 216-221.
Fresan, A., Apiquian, R., Fuente-Sandoval, C., Loyzaga, C., Garcia-Anaya, M., Meyenberg,
N., & Nicolini, H. 2005, "Violent behavior in schizophrenic patients: Relationship with
clinical symptoms.", Aggressive Behavior, vol. 31, pp. 511-520.
Friis, S. 1986, "Characteristics of a good ward atmosphere", Acta Psychiatrica Scandinavica,

vol. 74, pp. 469-473.
Frueh, B., Knapp, R. G., Cusck, K. J., Grubaugh, A. L., Sauvageot, J. A., Cousins, V. C.,
Yim, E., Robins, C. S., Monnier, J., & Hiers, T. G. 2005, "Patients' Reports of Traumatic or
harmful experiences Within the Psychiatric Setting", Psychiatric Services, vol. 56, no. 9, pp.
1123-1133.
Fullam, R. S. & Dolan, M. C. 193, "Executive function and in-patient violence in forensic
patients with schizophrenia", British Journal of Psychiatry. no. 3, pp. 247-253.
Gebhardt, R. P. & Steinert, T. 1999, "Should severely disturbed psychiatric patients be

distributed or concentrated in specialized wards? An empirical study on the effects of hospital
organization on ward atmosphere, aggressive behavior, and sexual molestation", The Journal
of the Association of European Psychiatrists., vol. 14, no. 5, pp. 291-297.
Gerberich, S. G., Church, T. R., McGovern, P. M., Hansen, H., Nachreiner, N. M., Geisser,
M. S., Ryan, A. D., Mongin, S. J., Watt, G. D., & Jurek, A. 2005, "Risk factors for work-
related assaults on nurses", Epidemiology, vol. 16, no. 5, pp. 704-709.
Gerolamo, A. M. 2008, "Measuring adverse outcomes in inpatient psychiatry: the reliability
of nurse recall", Archives of Psychiatric Nursing, vol. 22, no. 2, pp. 95-103.
Gillig, P. M., Markert, R., Barron, J., & Coleman, F. 1998, "A comparison of staff and patient
perceptions of the causes and cures of physical aggression on a psychiatric unit", Psychiatric
Quarterly, vol. 69, no. 1, pp. 45-60.
Goldberg, B. R., Serper, M. R., Sheets, M., Beech, D., Dill, C., & Duffy, K. G. 2007,
"Predictions of aggression on the psychiatric inpatient service: self-esteem, narcissism, and
theory of mind deficits", Journal of Nervous & Mental Disease. no. 5, pp. 436-442.
Goodykoontz, L. & Herrick, C. A. 1990, "Evaluation of an Inservice Education Program

Regarding Aggressive Behavior in a Psychiatric Unit", The Journal of Continuing Education
in Nursing, vol. 21, no. 3, pp. 129-133.
Gorden, J., Gorden, C., & Gardener, D. 1996, "A study of assaultive/aggressive behaviour on
staff by patients/clients in psychiatric facilities", Journal of Occupational Health and Safety,
vol. 12, no. 2, pp. 169-177.
Grainger, C. & Whiteford, H. 1993, "Assault on staff in psychiatric hospitals: a safety issue",
Australian & New Zealand Journal of Psychiatry, vol. 27, no. 2, pp. 324-328.
Grassi, L., Peron, L., Marangoni, C., Zanchi, P., & Vanni, A. 2001, "Characterisitcs of
violent behaviour in acute psychiatric inpatients: a 5 year Italian study", Acta Psychiatrica
Scandinavica, vol. 104, pp. 273-279.
Grassi, L., Biancosino, B., Marmai, L., Kotrotsiou, V., Zanchi, P., Peron, L., Marangoni, C.,
Vanni, A., & Barbui, C. 2006, "Violence in psychiatric units: a 7-year Italian study of
persistently assaultive patients", Social Psychiatry & Psychiatric Epidemiology, vol. 41, no.
9, pp. 698-703.
Gray, N. S., Hill, C., McGleish, A., Timmons, D., MacCulloch, M., & Snowdon, R. 2003,
"Prediction of violence and self-harm in mentally disordered offenders: A prospective study
of the efficacy of HCR-20, PCL-R, and psychiatric symptomatology.", Journal of Consulting
& Clinical Psychology, vol. 71, no. 3, pp. 443-451.
Greenfield, T. K., McNiel, D. E., & Binder, R. L. 1989, "Violent behavior and length of
psychiatric hospitalization", Hospital & Community Psychiatry, vol. 40, no. 8, pp. 809-814.
Grenade, G. & Macdonald, E. 1995, "Risk of physical assaults among student nurses",
Occupational Medicine (Oxford), vol. 45, no. 5, pp. 256-258.
Grevatt, M., Thomas-Peter, B., & Hughes, G. 2004, "Violence, mental disorder and risk
assessment: can structured clinical assessments predict the short-term risk of inpatient
violence?", The Journal of Forensic Psychiatry and Psychology, vol. 15, no. 2, pp. 278-292.
Grube, M. 2007, "Gender differences in aggressive behavior at admission to a psychiatric

hospital", Aggressive Behavior, vol. 33, no. 2, pp. 97-103Apr.
Gudjonsson, G., Rabe-Hesketh, S., & Szmukler, G. 2004, "Management of psychiatric

inpatient violence: patient ethnicity and use of medication, restraint and seclusion", British
Journal of Psychiatry, vol. 184, pp. 258-262.
Gudjonsson, G. H., Rabe-Hesketh, S., & Wilson, C. 1999, "Violent incidents on a medium
secure unit over a 17-year period", Journal of Forensic Psychiatry, vol. 10, pp. 249-263.
Gudjonsson, G. H., Rabe-Hesketh, S., & Wilson, C. 2000, "Violent incidents in a psychiatric
hospital. The target of assault and the management of incidents", Journal of Forensic
Haffke, E. & Reid, W. 1983, "Violence Against mental Health Personnel in Nebraska", in
Lion, J.and Reid, W.(Eds) Assaults Within psychiatric Facilities.Orlando: Grune and
Stratton., vol. 91-102.
Hagen.D.Q., Mikolajczak, J., & Wright, R. 1972, "Aggression in Psychiatric Patients",

Comprehensive Psychiatry, vol. 13(481-487).
Hahn, S., Needham I., Abderbalden, C., Duxbury J., & Halfens, R. 2006, "The effect of a
training course on mental health nurses' atitudes on the reasons of patient aggression and its
management", Journal of Psychiatric and Mental Health Nursing, vol. 13, pp. 197-204.
Haider, I. I. 1997, "Violence by psychiatric inpatients", Journal of the College of Physicians

& Surgeons Pakistan., vol. 7, no. 4, pp. 170-172.
Haim, R. 2002, "Predictions made by psychiatrists and psychiatric nurses of violence by

patients", Psychiatric Services, vol. 53, pp. 622-624.
Haller, R. M. & Deluty, R. H. 1990, "Characteristics of psychiatric inpatients who assault

staff severely", Journal of Nervous & Mental Disease, vol. 178, no. 8, pp. 536-537.
Hamadeh, R. R., Al Alaiwat, B., & Al Ansari, A. 2003, "Assaults and nonpatient-induced
injuries among psychiatric nursing staff In Bahrain.", Issues in Mental Health Nursing., vol.
24, no. 4, pp. 409-417.
Hanson, R. & Balk, J. 1992, "A replication study of staff injuries in a state hospital", Hospital
and Community Psychiatry, vol. 43, no. 8, pp. 836-837.
Hardie, T. 1999, "Crowding and violent behaviour: the influence of patient density on violent
and self-harming behaviour at a medium secure unit", Medicine, Science and the Law, vol.
39, pp. 161-166.
Harris, C. T. & Varney, G. W. 1986, "A ten-year study of assaults and assaulters on a
maximum security psychiatric unit", Journal of Interpersonal Violence, vol. 1, pp. 173-191.
Harris, G., Rice, M. E., & M 1986, "Staff injuries sustained during altercations with
psychiatric patients", Journal of Interpersonal Violence, vol. 1(2) : 193 - 211.
Hatch-Maillette, M. A., Scalora, M. J., Bader, S. M., & Bornstein, B. H. 2007, "A gender-
based incidence study of workplace violence in psychiatric and forensic settings", Violence &
Victims, vol. 22, no. 4, pp. 449-462.
Hatti, S., Dubin, W., & Weiss, K. 1982, "A study of circumstances surrounding patient
assaults on psychiatrists", Hospital and Community Psychiatry, vol. 33, pp. 660-661.
Heilbrun, K. 1998, "Inpatient and post discharge aggression in mentally disordered offenders:
The role of psychopathy", Journal of Interpersonal Violence, vol. 13, pp. 514-527.
Helmuth, R. 1994, "Nursing staff educational preparation and patient inflicted injuries in a
160 bed psychiatric hospital", Alaska Medicine, vol. 36, no. 4 (Dec), pp. 189-192.
Hesketh, K. L., Duncan, S., Estabrooks, C. A., Reimer, M. A., Giovannetti, P., Hyndman, K.,
& Acorn, S. 2003, "Workplace violence in Alberta and British Columbia hospitals.", Health
Policy, vol. 63, pp. 311-321.
Hildebrand, M., De-Ruiter, C., & Nijman, H. 2003, "PCL-R Psychopathy Predicts Disruptive
Behavior Among Male Offenders in a Dutch Forensic Psychiatric Hospital", Journal of
Interpersonal Violence, vol. 18, no. 10, pp. 1-17.
Hillbrand, M. 1992, "Self-directed and other-directed aggressive behaviour in a foresnic

sample", Suicide and Life-Threatening Behaviour, vol. 22, pp. 333-340.
Hillbrand, M., Foster, H. G., & Spitz, R. T. 1996, "Characteristics and cost of staff injuries in
a forensic hospital", Psychiatric Services, vol. 47, no. 10, pp. 1123-1125.
Hills, D. 2008, "Relationships between aggression management training, perceived self-

efficacy and rural general hospital nurses' experiences of patient aggression", Contemporary
Nurse, vol. 31, no. 1, pp. 20-31.
Hinsby, K. & Baker, M. 2004, "Patient and nurse accounts of violent incidents in a Medium
Secure Unit", Journal of Psychiatric and Mental Health Nursing, vol. 11, pp. 341-347.
Hodgins, S., Alderton, J., Cree, A., Aboud, A., & Mak, T. 2007, "Aggressive behaviour,
victimisation and crime among severely mentally ill patients requiring hospitalisation",
British Journal of Psychiatry, vol. 191, pp. 343-350.
Hodgkinson, P., Hillis, T., & Russel, D. 1984, "Assaults on Staff in psychiatric Hospitals",
Nursing Times, vol. 80, no. 18, pp. 44-46.
Hodgkinson, P., McIvor, L. L., & Phillips, M. 1985, "Patient Assaults on Staff in a
Psychiatric Hospital. A two year retrospective study", Medicine, Science and the Law, vol.
28, pp. 288-294.
Holden, B. & Gitlesen, J. P. 2008, "The relationship between psychiatric symptomatology

and motivation of challenging behaviour: a preliminary study", Research in Developmental
Disabilities., vol. 29, no. 5, pp. 408-413.
Hoptman, M. J., Yates, K. F., Patalinjug, M. B., Wack, R. C., & Convit, A. 1999, "Clinical
prediction of assaultive behavior among male psychiatric patients at a maximum-security
forensic facility.", Psychiatric Services, vol. 50, no. 11, pp. 1461-1466.
Hornsveld, R. H., Nijman, H. L., Hollin, C. R., & Kraaimaat, F. W. 2007, "Development of
the Observation Scale for Aggressive Behavior (OSAB) for Dutch forensic psychiatric
inpatients with an antisocial personality disorder", International Journal of Law &
Psychiatry, vol. 30, no. 6, pp. 480-491.
Hornsveld, R. H. J., Nijman, H. L. I., & Kraaimaat, F. W. 2008, "Aggression control therapy
for violent forensic psychiatric patients: First results", Psychology, Crime & Law, vol. 14, no.
1, pp. 1-18.
Huber, C. G., Lambert, M., Naber, D., Schacht, A., Hundemer, H. P., Wagner, T. T., &
Schimmelmann, B. G. 2008, "Validation of a Clinical Global Impression Scale for
Aggression (CGI-A) in a sample of 558 psychiatric patients", Schizophrenia Research, vol.
100, no. 1, pp. 342-348.
Huchzermeier, C., Bruss, E., Geiger, F., Kernbichler, A., & Aldenhoff, J. 2008, "Predictive
validity of the psychopathy checklist: screening version for intramural behaviour in violent
offenders-a prospective study at a secure psychiatric hospital in Germany", Canadian Journal
of Psychiatry - Revue Canadienne de Psychiatrie, vol. 53, no. 6, pp. 384-391.
Hunter, M. E. & Love, C. C. 1993, "Types of weapons and patterns of use in a forensic
hospital", Hospital and Community Psychiatry, vol. 44(11): 1082-1085.
Hunter, M. E. & Love, C. C. 1996, "Total Quality Management and the Reduction of
Inpatient Violence and Costs in a Forensic Psychiatric Hospital", Psychiatric Services, vol.
47, no. 7, pp. 751-754.
Huss, M. T. & Zeiss, R. A. 2004, "Clinical assessment of violence from inpatient records: A
comparison of individual and aggregate decision making across risk strategies.",
International Journal of Forensic Mental Health, vol. 3, pp. 139-147.
Infantino, J. A. & Musingo, S. A. 1985, "Assaults and Injuries Among Staff with and without
Training in Aggression Control techniques", Hospital and Community Psychiatry, vol. 36,
no. 12, pp. 1312-1314.
Inoue, M., Tsukano, K., Muraoka, M., Kaneko, F., & Okamura, H. 2006, "Psychological
impact of verbal abuse and violence by patients on nurses working in psychiatric
departments", Psychiatry & Clinical Neurosciences., vol. 60, no. 1, pp. 29-36.
Ionno, J. 1983, "A Prospective Study of Assaultive Behaviour in Female Psychiatric

Inpatients", in Lion, J.and Reid, W.(Eds) Assaults Within psychiatric Facilities.Orlando:
Grune and Stratton. pp. 71-80.
Ireland, J. L. & Rowley, J. 7 A.D., "Sectioned offenders presenting with enduring mental
illness: a study exploring behaviors indicative of bullying", Aggressive Behavior., vol. 33, no.
5, pp. 377-388.
Ireland, J. L. 2004, "Nature, extent and caused of bullying among personality-disordered

patients in a high secure hospital", Aggressive Behavior, vol. 30, pp. 229-242.
Ireland, J. L. 2005, "Exploring Definitions of Bullying Among Personality Disordered

Patients in a Maximum-Secure Hospital", Aggressive Behavior, vol. 31, pp. 359-373.
Ireland, J. L. & Bescoby, N. 2005, "Behavioural Assessment of Bullying Behaviour Among

Personality Disordered Patients in a High Secure Hospital", Aggressive Behavior, vol. 31, no.
1, pp. 67-83.
Ireland, J. L. 2006, "Bullying Among Mentally-Ill Patients Detained in a High-Secure
Hospital: An Exploratory Study of the Perceptions of Staff and Patients into How Bullying is
Defined", Aggressive Behavior , vol. 32, no. 5, pp. 451-463.
Ito, H., Eisen, S., Sederer, L., Yamada, O., & Tachimori, H. 2001, "Factors affecting
psychiatric nurses' intention to leave their current job", Psychiatric Services, vol. 52, no. 2,
pp. 232-234.
James, D., Fineberg, N., Shah, A., & Priest, R. 1990, "An Increase in Violence on an Acute
Psychiatric Ward: A Study of Associated Factors", British Journal of Psychiatry, vol. 156,
pp. 846-852.
Jansen, G., Dassen, T., & Moorer, P. 1997, "The Perception of Aggression", Scandinavia
Journal of Caring Sciences, vol. 1, pp. 51-55.
Jansen, G. J., Middel, B., Dassen, T. W., & Reijneveld, M. S. 1920, "Cross-cultural
differences in psychiatric nurses' attitudes to inpatient aggression", Archives of Psychiatric
Nursing. no. 2, pp. 82-93.
Jansen, G. J., Dassen, T. W. N., Burgerhof, J. G. M., & Middel, B. 2006, "Psychiatric nurses'
attitudes towards inpatient aggression: Preliminary report of the development of Attitude
Towards Aggression Scale (ATAS)", Aggressive Behavior, vol. 32, no. 1, pp. 44-53.
Johnson, B., Martin, M., Guha, M., & Montgomery, P. 1997, "The experience of thought-
disordered individuals preceding an agressive incident", Journal of Psychiatric Nursing and
Mental Health Services, vol. 4, no. 3, pp. 213-220.
Johnson, M. E. & Delaney, K. R. 2007, "Keeping the unit safe: the anatomy of escalation",
Journal of the American Psychiatric Nurses Association, vol. 13, no. 1, pp. 42-52.
Johnston, R. & Lundy, B. W. 1982, "Disruptive behavior by hospitalized patients following

movie viewing", Hospital & Community Psychiatry, vol. 33, no. 12, pp. 1015-1017.
Jones, M. K. 1985, "Patient Violence: report of 200 incidents", Journal of Psychosocial

Nursing, vol. 23, no. 6, pp. 12-17.
Jones, N. T., Sheitman, B., Hazelrigg, M., Carmel, H., Williams, J., & Paesler, B. 2007,
"Development of a clinical instrument to record sexual aggression in an inpatient psychiatric
setting", Journal of Sexual Aggression, vol. 13, no. 1, pp. 51-58.
Jonker, E. J., Goossens, P. J. J., Steenhuis, I. H. M., & Oud, N. E. 2008, "Patient aggression
in clinical psychiatry: Perceptions of mental health nurses", Journal of Psychiatric and
Mental Health Nursing, vol. 15, no. 6, pp. 492-499.
Joyal, C. C., Gendron, C., & Cote, G. 2008, "Nature and frequency of aggressive behaviours
among long-term inpatients with schizophrenia: a 6-month report using the modified overt
aggression scale", Canadian Journal of Psychiatry - Revue Canadienne de Psychiatrie, vol.
53, no. 7, pp. 478-481.
Karson, C. & Bigelow, L. 1987, "Violent behaviour in schizophrenic inpatients", Journal of

Nervous Mental Disorders, vol. 175, pp. 161-164.
Katz, P. & Kirkland, F. R. 1990, "Violence and Social Structure on Mental Hospital Wards",
Kennedy, J., Harrison, J., & Hillis, T. 1995, "Analysis of violent incidents in a regional
secure unit", Medicine, Science and the Law, vol. 35, pp. 226-231.
Kennedy, M. G. 1993, "Relationship between psychiatric diagnosis and patient aggression",

Issues in Mental Health Nursing., vol. 14, no. 3 (Sep), pp. 263-273.
Ketelsen, R., Zechert, C., Driessen, M., & Schulz, M. 2007, "Characteristics of aggression in
a German Psychiatric hopsital and predictors of patients at risk", Journal of Psychiatric and
Kho, K., Sensky, T., Mortimer, A., & Corcos, C. 1998, "Prospective study into factors
associated with aggressive incidents in psychiatric acute admissions wards", British Journal
of Psychiatry, vol. 172, pp. 38-43.
Kiely, S., McCafferty, G., & McMahon, A. 1999, "Danger at work? - violence and mental
health nursing", Mental health Practice, vol. 2, no. 7, pp. 4-5.
Kindy, D., Peterson, S., & Parkhurst, D. 2005, "Perilous work: Nurses' experiences in
psychiatric units with high risks of assault", Archives of Psychiatric Nursing, vol. 19, no. 4,
pp. 169-175.
Knowles, S. F., Coyne, S. M., & Brown, S. L. 2008, "Sex differences in aggressive incidents
towards staff in secure services", Journal of Forensic Psychiatry & Psychology, vol. 19, no.
4, pp. 620-631.
Kohen, D. 2002, "Nurses' uniforms", Psychiatric Bulletin, vol. 26, no. 4, p. 156.
Krakowoski, M., Jaeger, J., & Volavka, J. 1988, "Violence and psychopathology: A
longitudinal study", Comprehensive Psychiatry, vol. 29, pp. 174-181.
Krakowski M, Convit, A., Jaeger, J., Lin, S., & Volavka, J. 1989, "Neurological impairment
in violent schizophrenic inpatients.", American Journal of Psychaitry, vol. 146, pp. 849-853.
Krakowski, M. & Czobor, P. 1997, "Violence in psychiatric patients: the role of psychosis,
frontal lobe impairment, and ward turmoil", Comprehensive Psychiatry, vol. 38, no. 4 (Aug),
pp. 230-236.
Krakowski, M., Czobor, P., & Chou, C. Y. 1999, "Course of Violence in Patients with
Schizophrenia: Relationship to Clinical Symptoms", Schizophrenia Bulletin, vol. 25, no. 3,
pp. 505-517.
Krakowski, M. I., Convit, A., Jaeger, J., Lin, S., & Volavka, J. 1989, "Inpatient violence: trait
and state", Journal of Psychiatric Research, vol. 23, no. 1, pp. 57-64.
Kraus, J. E. & Sheitman, B. B. 2004, "Characteristics of Violent Behavior in a Large State

Psychiatric Hospital", Psychiatric Services., vol. 55, no. 2, pp. 183-185.
Kumar, S., Guite, H., & Thornicroft, G. 2001, "Service Users' Experience of Violence within
a Mental health System: A Study Using Grounded Theory Approach", Journal of mental
Health, vol. 10, no. 6, pp. 597-611.
Lam, J. N., McNiel, D. E., & Binder, R. L. 2000, "The relationship between patients' gender
and violence leading to staff injuries", Psychiatric Services., vol. 51, no. 9, pp. 1167-1170.
Lancee, W. J., Gallop, R., McCay, E., & Toner, B. 1995, "The relationship between nurses'
limit-setting styles and anger in psychiatric inpatients", Psychiatric Services, vol. 46, no. 6,
pp. 609-613.
Langsrud, K., Linaker, O. M., & Morken, G. 2007, "Staff injuries after patient-staff
incidences in psychiatric acute wards", Nordic Journal of Psychiatry, vol. 61, no. 2, pp. 121-
125.
Lanza, M. & Kayne, H. 1997, "Staffing of inpatient units and assault by patients", Journal of
the American Psychiatric Nurses Association, vol. 3, no. 2, pp. 42-48.
Lanza, M. L. 1983, "The Reactions of Nursing Staff to Physical Assault by a Patient",

Hospital of Community Psychiatry, vol. 34, no. 1, pp. 45-47.
Lanza, M. L. 1985, "How Nurses React to Patient Assault", Journal of Psychosocial

Nursing, vol. 23, no. 6, pp. 6-11.
Lanza, M. L., Milner, J., & Riley, E. 1988, "Predictors of Patient Assault on Acute Inpatient
Psychiatric Units: A Pilot Study", Issues in Mental Health Nursing, vol. 9, no. 3, pp. 259-270.
Lanza, M. L. 1988, "Factors Relevant to Patient Assault", Issues in Mental Health Nursing,
vol. 9, no. 239, p. 257.
Lanza, M. L., Kayne, H. L., Hicks, C., & Milner, J. 1991, "Nursing Staff Characteristics
Related to Patient Assault", Issues in Mental Health Nursing, vol. 12, no. 3, pp. 253-265.
Lanza, M. L. & Carifio, J. 1991, "Blaming the victim: complex (nonlinear) patterns of causal
attribution by nurses in response to vignettes of a patient assaulting a nurse", Journal of
Emergency Nursing, vol. 17, no. 5, pp. 299-309.
Lanza, M. L., Kayne, H. L., Pattison, I., Hicks, C., & Islam, S. 1994, "Predicting
violence:nursing daignosis versus psychiatric diagnosis", Nursing Diagnosis, vol. 5, no. 4,
pp. 151-157.
Lanza, M. L. & Kayne, H. L. 1995, "Patient Assault: A Comparison of Patient and Staff
Perceptions", Issues in Mental Health Nursing, vol. 16, pp. 129-141.
Larkin, E., Silvester, M., & Jones, S. 1988, "A Preliminary Study of Violent Incidents in a
Speical Hospital (Rampton)", British Journal of Psychiatry, vol. 153, pp. 226-231.
Lawn, S. & Pols, R. 2003, "Nicotine withdrawal: Pathway to aggression and assault in the
locked psychiatric ward?", Australasian Psychiatry., vol. 11, no. 2, pp. 199-203.
Lawoko, S., Soares, J., & Nolan, P. 2004, "Violence towards psychiatric staff: a comparison
of gender, job and environmental characteristics in England and Sweden", Work & Stress,
vol. 18, no. 1, pp. 39-55.
Lee, H. K., Villar, O., Juthani, N., & Bluestone, H. 1989, "Characteristics and behaviour of
patients involved in psychiatric ward incidents", Hospital and Community Psychiatry, vol.
40, no. 12, pp. 1295-1297.
Lehmann, L., McCormick, R., & Kizer, K. 1999, "A survey of assaultive behaviour in a
Veterans Health Administration Centre", Psychiatric Services, vol. 50, pp. 384-389.
Lehmann, L., McCormick, R., & Kizer, K. 1999, "A survey of assaultive behaviour in a
Veterans Health Administration Centre", Psychiatric Services, vol. 50, pp. 384-389.
LePage, J. P., DelBen, K., Pollard, S., McGhee, M., VanHorn, L., Murph, J., Lewis, P.,
Aboraya, A., & Mogge, N. 2003, "Reducing assaults on an acute psychiatric unit using a
token economy: A 2-year follow-up", Behavioral Interventions., vol. 18, no. 3, pp. 179-190.
LePage, J. P., McGhee, M., Aboraya, A., Murphy, J., VanHorn, L., Pollard, S., & Dean, P.
2005, "Evaluating risk factors for violence at the inpatient unit level: combining young adult
patients and those with mental retardation", Applied Nursing Research, vol. 18, no. 2, pp.
117-121.
Levy, P. & Hartocollis, P. 1976, "Nursing Aides and Patient Violence", American Journal of
Lim, L., Tobin, M., & Falkowski, W. 1991, "The characteristics of patients who display
violent behaviour in a psychiatric hospital", British Journal of Clinical and Social Psychiatry,
vol. 8, no. 1, pp. 12-18.
Linaker, O. M. & Busch-Iversen, H. 1995, "Predictors of Imminent Violence in Psychiatric

Inpatients", Acta psychiatr.scand., vol. 92, no. 4, pp. 250-254.
Linhorst, D. M. & Scott, L. P. 2004, "Assaultive Behavior in State Psychiatric Hospitals:

Differences Between Forensic and Nonforensic Patients. [References]", Journal of
Interpersonal Violence., vol. 19, no. 8, pp. 857-874.
Lion, J. R. & Pastermak, S. A. 1973, "Countertransference Reactions to Violent Patients",

American Journal of Psychiatry, vol. 130, no. 2, pp. 207-210.
Lion, R. J. & et al. 1981, "Underreporting of assaults on staff in a state hopsital", Hospital
and Community Psychiatry, vol. 32 815-825, pp. 815-825.
Lipscomb, J., McPhaul, K., Rosen, J., Brown, J. G., Choi, M., Soeken, K., Vignola, V.,
Wagoner, D., Foley, J., & Porter, P. 2006, "Violence prevention in the mental health setting:
the New York state experience", Canadian Journal of Nursing Research, vol. 38, no. 4, pp.
96-117.
Longo, D. A. & Bisconer, S. W. 2003, "Treatment of aggression for an adult diagnosed with
schizophrenia at a public psychiatric hospital", Professional Psychology Research and
Practice, vol. 34, no. 2, pp. 177-179.
Love, C. & Hunter, M. 1996, "Violence in public sector psychiatric hospitals. Benchmarking
nursing staff injury rates", Journal of Psychosocial Nursing and Mental Health Services, vol.
34, no. 5, pp. 30-34.
Love, C. & Hunter, M. 1999, "The Atascadero State Hospital experience: engaging patients
in violence prevention", Journal of Psychosocial Nursing and Mental Health Services, vol.
37, no. 9, pp. 32-36.
Lowe, T. 1992, "Characteristics of effective nursing interventions in the management of

challenging behaviour", Journal of Advanced Nursing, vol. 17, pp. 1226-1232.
Lowenstein, M., Binder, R. L., & McNiel, D. E. 1990, "The relationship between admission
symptoms and hospital assaults", Hospital and Community Psychiatry, vol. 41, no. 3, pp.
311-313.
Lu, C. H., Wang, T. F., & Liu, C. Y. 2007, "Psychiatric nurses' reactions to assault upon them
by inpatients: A survey in Taiwan", Psychological Reports, vol. 100, no. 3, pp. 777-782.
Lucas, M. & Stevenson, D. 2006, "Violence and abuse in psychiatric in-patient institutions: a
South African perspective", International Journal of Law & Psychiatry, vol. 29, no. 3, pp.
195-203.
Madden, D. J., Lion, J. R., & Penna, M. 1976, "Assaults on psychiatrists by patients",
American Journal of Psychiatry, vol. 133, pp. 422-425.
Maier, G., Van Rybroek, G., & Mays, D. 1994, "A report on staff injuries and ambulatory
restraints: dealing with patient aggression", Journal of Psychosocial Nursing and Mental
Health Service, vol. 32, no. 11, pp. 23-29.
Manfredini, R., Vanni, A., Peron, L., La Cecilia, O., Smolensky, M. H., & Grassi, L. 2001,
"Day-night variation in aggressive behavior among psychiatric inpatients", Chronobiology
International., vol. 18, no. 3, pp. 503-511.
Margari, F., Matarazzo, R., Casacchia, M., Roncone, R., Dieci, M., Safran, S., Fiori, G.,
Simoni, L., & The EPICA Study Group 2005, "Italian validation of MOAS and NOSIE: a
useful package for psychiatric assessment and monitoring of aggressive behaviours",
International Journal of Methods in Psychiatric Research, vol. 14, no. 2, pp. 109-118.
McGeorge, M., Lelliott, P., Stewart, J., & Royal College of Psychiatrist Research Unit, L.
2001, "Managing Violence in Psychiatric Wards: Preliminary Findings of a Multi-centre
Audit", Mental Health Care, vol. 31, no. 11, pp. 366-369.
McKenzie, B. & Curr, H. 2005, "Predicting violence in a medium secure setting: a study
using the historical and clinical scales of the HCR-20", British Journal of Forensic Practice,
vol. 7, no. 3, pp. 22-28.
McNiel, D., Binder, R., & Greenfield, T. 1988, "Predictors of violence in civilly committed
acute psychiatric patients", American Journal of Psychiatry, vol. 145, no. 8, pp. 965-970.
McNiel, D., Lam, J., & Binder, R. 2000, "Relevance of interrater agreement to violence risk
assessment.", Journal of Consulting & Clinical Psychology, vol. 68, no. 6, pp. 1111-1115.
McNiel, D., Gregory, A. L., Lam, J., Binder, R. L., & Sullivan, G. 2003, "Utility of decision
support tools for assessing acute risk of violence.", Journal of Consulting & Clinical
McNiel, D. E. & Binder, R. L. 1989, "Relationship between preadmission threats and later
violent behavior by Acute psychiatric inpatients", Hospital and Community Psychiatry, vol.
40, no. 6, pp. 605-608.
McNiel, D. E. & Binder, R. L. 1991, "Clinical Assessment of the Risk of Violence Among
Psychiatric Inpatients", American Journal of Psychiatry, vol. 148, no. 10, pp. 1317-1321.
McNiel, D. E. & Binder, R. L. 1994, "The relationship between acute psychiatric symptoms,
diagnosis, and short-term risk of violence", Hospital and Community Psychiatry, vol. 45, no.
2, pp. 133-137.
McNiel, D. E., Sandberg, D. A., & Binder, R. L. 1998, "The relationship between confidence
and accuracy in clinical assessment of psychiatric patients potential for violence", Law &
Human Behavior, vol. 22, no. 6, pp. 655-669.
Meehan, T., McIntosh, W., & Bergen, H. 2006, "Aggressive behaviour in the high-secure
forensic setting: the perceptions of patients", Journal of Psychiatric and Mental Health
Nursing, vol. 13, pp. 19-25.
Meehan, T., Fjeldsoe, K., Stedman, T., & Duraiappah, V. 2006, "Reducing aggressive
behaviour and staff injuries: a multi-strategy approach", Australian Health Review, vol. 30,
no. 2, pp. 203-210.
Mellesdal, L. 2003, "Aggression on a Psychiatric Acute Ward: A Three-Year Prospective

Study", Psychological Reports, vol. 92, pp. 1229-1248.
Merecz, D., Rymaszewska, J., Moscicka, A., Kiejna, A., & Jarosz-Nowak, J. 2006, "Violence
at the workplace--a questionnaire survey of nurses", European Psychiatry: the Journal of the
Association of European Psychiatrists.21(7):442-50.
Mezey, G., Hassell, Y., & Bartlett, A. 2005, "Safety of women in mixed-sex and single-sex
medium secure units: staff and patient perceptions", British Journal of Psychiatry, vol. 187,
no. 6, pp. 579-582.
Middleby-Clements, J. L. & Grenyer, B. F. S. 2007, "Zero tolerance approach to aggression

and its impact upon mental health staff attitudes", Austrailian and New Zealand Journal of
Milius, A. C. 1990, "Experienced psychiatric nurses' prediction of inpatient aggression",

Kansas Nurse, vol. 65, no. 10, pp. 1-10.
Miller, R., Zadolinnyj, K., & Hafner, J. 1993, "Profiles and Predictors of Assaultiveness for
Different Psychiatric Ward Populations", Am J Psychiatry, vol. 150, no. 9, pp. 1368-1373.
Mills, A. 1997, "Incident reports in secure psychiatric hospitals", Nursing Standard, vol. 12,
no. 6, pp. 34-35.
Morken, G., Linaker, O. M., & Langsrud, K. 1999, "Weekly and daily variations in patient-
staff incidents in psychiatric acute wards", Nordic Journal of Psychiatry., vol. 53, no. 4, pp.
293-295.
Morken, G. & Linaker, O. M. 2000, "Seasonal variation of violence in psychiatric patients

and the general population", European Journal of Psychiatry., vol. 14, no. 3, pp. 153-159.
Morrison, E., Morman, G., Bonner, G., Taylor, C., Abraham, I., & Lathan, L. 2002,
"Reducing Staff Injuries and Violence in a Forensic Psychiatric Setting", Archives of
Psychiatric Nursing, vol. XVI, no. 3, pp. 108-117.
Morrison, E. F. 1990, "Violent Psychiatric Inpatients in a Public Hospital", Scholarly Inquiry

for Nursing Practice: An International Journal, vol. 4(1): 65-82.
Mortimer, A. 1995, "Reducing Violence on a Secure Ward", Psychiatric Bulletin, vol. 19, pp.
605-608.
Murray, G. & McKenzie, K. 1999, "The relationship between staff sickness levels and client
assault levels in health service unit for people with an intellectual disability and severely
challenging behaviour", Journal of applied research in intellectual disabilities, vol. 12, pp.
263-268.
Murray, M. G. & Snyder, J. C. 1991, "When staff are assaulted. A nursing consultation
support service", Journal of Psychosocial Nursing & Mental Health Services., vol. 29, no. 7,
pp. 24-29.
Myers, K. & Dunner, D. 1984, "Self and other directed violence on a closed acute care ward",
Psychiatric Quarterly, vol. 56, pp. 178-188.
Needham, I., Abderhalden, C., Meer, R., Dassen, T., Haug, H., Halfens, R., & Fischer, J.
2004, "The effectiveness of two interventions in the management of patient violence in acute
mental inpatient settings: report on a pilot study", Journal of Psychiatric and Mental Health
Needham, I., Abderbalden, C., Dassen, T., Haug, H. J., & Fischer, E. 2002, "Coercive
Procedures and Facilities in Swiss Psychiatry", Swiss Med Weekly, vol. 132, pp. 253-258.
Needham, I., Abderhalden, C., Haug, H. J., Dassen, T., Halfens, R. J. G., & Fischer, J. E. The
effect of a training course in aggression management on the prevalence of aggression and
coercive measures in inpatient psychiatric settings: A randomised controlled trial. 2004.
Ref Type: Unpublished Work
Ng, B., Kumar, S., Ranclaud, M., & Robinson, E. 2001, "Ward crowding and incidents of
violence on an acute psychiatric inpatient unit", Psychiatric Services., vol. 52, no. 4, pp. 521-
525.
Nicholls, T. L., Ogloff, J., & Douglas, K. S. 2004, "Assessing risk for violence among male
and female civil psychiatric patients: The HCR-12, PCL:SV and VSC", Behavioral Sciences
and the Law, vol. 22, pp. 127-158.
Nicholls, T. L., Brink, J., Greaves, C., Lussier, P., & Verdun-Jones, S. 2009, "Forensic
psychiatric inpatients and aggression: an exploration of incidence, prevalence, severity, and
interventions by gender", International Journal of Law & Psychiatry, vol. 32, no. 1, pp. 23-
30.
Nijman, H., Allertz, W., Merckelbach, H., & Ravelli, D. 1997, "Aggressive Behaviour on an
Acute Psychiatric Admissions Ward", European Journal of Psychiatry, vol. 11, no. 2, pp.
106-114.
Nijman, H., Merckelbach, H., Evers, C., Palmstierna, T., & Campo, J. 2002, "Prediction of
Aggression on a Locked Psychiatric Amission Ward", Acta Psychiatrica Scandinavica, vol.
105, pp. 1-6.
Nijman, H. L., Merckelbach, H., & Campo, J. 1997, "Prevention of Aggressive Incidents on a
Closed Psychiatric Ward", Psychiatric Services, vol. 48, no. 5, pp. 694-698.
Nijman, H. L. I. & Rector, G. 1999, "Crowding and aggression on inpatient psychiatric

wards", Psychiatric Services., vol. 50, no. 6, pp. 830-831.
Noble, P. & Rodger, S. 1989, "Violence by Psychiatric In-patients", British Journal of

Nolan, K. A., Czobor, P., Roy, B. B., Platt, M. M., Shope, C. B., Citrome, L. L., & Volavka,
J. 2003, "Characteristics of assaultive behavior among psychaitric inpatients", Psychiatric
Services, vol. 54, no. 7, pp. 1012-1016.
Nolan, K. A. & Volavka, J. 2006, "Video recording in the assessment of violent incidents in
psychiatric hospitals", Journal of Psychiatric Practice, vol. 21, no. 1, pp. 58-63.
Nolan, K. A. & Citrome, L. 2008, "Reducing inpatient aggression: does paying attention pay
off?", Psychiatric Quarterly, vol. 79, no. 2, pp. 91-95.
Nolan, K. A., Volavka, J., Czobor, P., Sheitman, B., Lindenmayer, J. P., Citrome, L. L.,
McEvoy, J., & Lieberman, J. A. 2005, "Aggression and psychopathology in treatment-
resistant inpatients with schizophrenia and schizoaffective disorder", Journal of Psychiatric
Research, vol. 39, no. 1, pp. 109-115.
Nolan, P., Dalender, J., Soares, J., Thomsen, S., & Arnetz, B. 1999, "Violence in mental
health care: the experiences of mental health nurses and psychiatrists", Journal of Advanced
Nursing, vol. 30(4) 934-941.
Ogloff, J. R. P. & Daffern, M. 2006, "The Dynamic Appraisal of Situational Aggression: An

Instrument to Assess Risk for Imminent Aggression in Psychiatric Inpatients", Behavioral
Sciences & the Law, vol. 24, no. 6, pp. 799-813.
Omerov, M. & Wistedt, B. 1997, "Mangageable violence in a new ward for acutely admitted
patients", European Psychiatry: the Journal of the Association of European Psychiatrists.,
vol. 12, no. 6, pp. 311-315.
Omerov, M., Edman, G., & Wistedt, B. 2004, "Violence and threats of violence within
psychiatric care - A comparison of staff and patient experience of the same incident", Nordic
Journal of Psychiatry., vol. 58, no. 5, pp. 363-369.
Oulis, P., Lykouras, L., Dascalopoulou, E., & Psarros, C. 1996, "Aggression among
psychiatric inpatients in Greece", Psychopathology., vol. 29, no. 3, pp. 174-180.
Owen, C., Tarantello, C., Jones, M., & Tennant, C. 1998, "Violence and Aggression in
Psychiatric Units", Psychiatric Services, vol. 49, no. 11, pp. 1452-1456.
Owen, C., Tarantello, C., Jones, M., & Tennant, C. 1998, "Repetitively violent patients in
psychiatric units", Psychiatric Services., vol. 49, no. 11, pp. 1458-1461.
Owen, C., Tarantello, C., Jones, M., & Tennant, C. 1998, "Lunar cycles and violent
behaviour", Australian & New Zealand Journal of Psychiatry., vol. 32, no. 4, pp. 496-499.
Palmstierna, J., Huitfelt, B., & Wistedt, B. 1991, "The relationship of crowding and
aggressive behaviour on a psychiatric intensive care unit", Hospital and Community
Palmstierna, T. & Wistedt, B. 1989, "Risk Factors for Aggressive Behaviour are of Limited
Value in Predicting the Violent Behaviour of Acute Involuntarily Admitted Patients", Acta
Psychiatrica Scandinavica, vol. 81: 152-155.
Palmstierna, T., Lassenius, R., & Wistedt, B. 1989, "Evaluation of BPRS in relation to
aggressive behaviour by acute involuntarily admitted patients", Acta Psychiatrica
Scandinavica, vol. 79:313-316.
Palmstierna, T. & Wistedt, B. 1995, "Changes in the pattern of aggressive behaviour among
inpateints with changed ward organization", Acta psychiatr.scand., vol. 91: 32-35.
Palmstierna, T. & Barredal, E. 2006, "Evaluation of the Perception of Aggression Scale

(POAS) in Swedish nurses", Nordic Journal of Psychiatry, vol. 60, no. 6, pp. 447-451.
Parkes, J. 2003, "The nature and management of aggressive incidents in a medium secure
unit", Medicine, Science & the Law, vol. 43, no. 1, pp. 69-74.
Pearson, M., Wilmot, E., & Padi, M. 1986, "A study of violent behaviour among in-patients
in a psychiatric hospital", British Journal of Psychiatry, vol. 149, pp. 232-235.
Pieters, G., Speybrouck, E., de Gucht, V. +., & Joos, S. 2005, "Assaults by patients on
psychiatric trainees: Frequency and training issues", Psychiatric Bulletin, vol. 29, no. 5, pp.
168-170.
Poster, E. & Ryan, J. 1989, "Nurses' attitudes toward physical assaults by patients", Archives
of Psychiatric Nursing, vol. III, no. 6, pp. 315-322.
Poster, E. 1996, "A multinational study of psychiatric nursing staff's beliefs and concerns
about work safety and patient assault", Archives of Psychiatric Nursing, vol. 10, no. 6, pp.
365-373.
Poster, E. & Ryan, C. 1994, "A Multiregional Study of Nurses' Beliefs and Attitudes About
Work Safety and Patient Assault", Hospital and Community Psychiatry, vol. 45, no. 11, pp.
1104-1108.
Powell, G., Caan, W., & Crowe, M. 1994, "What events precede violent incidents in
psychiatric hospitals?", British Journal of Psychiatry, vol. 165, pp. 107-112.
Price, T. B., David, B., & Otis, D. 2004, "The use of restraint and seclusion in different racial
groups in an inpatient forensic setting", Journal of the American Academy of Psychiatry and
the Law, vol. 32, no. 2, pp. 163-168.
Privitera, M., Weisman, R., Cerulli, C., Tu, X., & Groman, A. 2005, "Violence toward mental
health staff and safety in the work environment", Occupational Medicine (Oxford), vol. 55,
pp. 480-486.
Quanbeck, C., McDermott, B. E., Lam, J., Eisenstark, H., Sokolov, G., & Scoatt, C. L. 2007,
"Categorization of Aggressive Acts Committed by Chrnoically Assaultive State Hospital
Patients", Psychiatric Services, vol. 58, no. 4, pp. 521-528.
Quirk, A., Lelliott, P., & Seale, C. 2004, "Service users' strategies for managing risk in the
volatile environment of an acute psychiatric ward", Social Science & Medicine., vol. 59, no.
12, pp. 2573-2583.
Rabinowitz, J. & Mark, M. 1999, "Risk factors for violence among long-stay psychiatric
patients: National study.", Acta Psychiatrica Scandinavica, vol. 99, no. 5, pp. 341-347.
Raja, M. & Azzoni, A. 2005, "Hostility and violence of acute psychiatric inpatients", Clinical
Practice and Epidemiology in Mental Health, vol. 1, no. 11.
Raja, M., Azzoni, A., & Lubich, L. 1997, "Aggressive and violent behaviors in a population
of psychiatric inpatients", Social Psychiatry and Psychiatric Epidemiology, vol. 32, no. 7, pp.
428-434.
Rasmussen, K. & Levander, S. 1996, "Individual rather than situational characteristics predict
violence in a maximum security hospital", Journal of Interpersonal Violence, vol. 11, no. 3,
pp. 376-390.
Rasmussen, K., Lavender, S., & Sletvold, H. 1995, "Aggressive and nonaggressive
schizophrenics: sympton profile and neuropsychological differences.", Psychology, Crime &
Law, vol. 15, pp. 397-408.
Rauter, U. K., de-Nesner, A., & Grandfield, S. 1997, "Up in Smoke? Linking Patient Assaults
to a Psychiatric Hospital's Smoking Ban", Journal of Psychiatric Nursing, vol. 35, no. 6, pp.
35-40.
Ray, C. L. & Subich, L. M. 1998, "Staff Assaults and Injuries in a Psychiatric Hospital as a
Function of Three Attitudinal variables", Issues in Mental Health Nursing, vol. 19, no. 3, pp.
277-289.
Rees, C. & Lehane, M. 1996, "Witnessing violence to staff: a study of nurses' experiences",
Nursing Standard., vol. 11, no. 13-15, pp. 45-47.
Reid, W., Bollinger, M., & Edwards, J. 1989, "Serious assaults by inpatients",
Psychosomatics, vol. 30, pp. 54-56.
Richter, D. & Berger, K. 2006, "Post-traumatic stress disorder following patient assaults
among staff members of mental health hospitals: A prospective longitudinal study", BMC
Psychiatry.Vol.6, 2006.Article Number: 15.Date of Publication: 10 APR 2006., vol. 6.
Rinn, R. C. 1976, "Effects of nursing apparel upon psychiatric inpatients' behavior",

Perceptual & Motor Skills, vol. 43, no. 3 pt 1, pp. 939-945.
Rix, G. 1987, "Staff sickness and its relaitonship to violent incidents on a regional secure
psychiatric unit", Journal of Advanced Nursing, vol. 12, pp. 223-228.
Rix, G. & Seymour, D. 1988, "Violent incidents on a regional secure unit", Journal of
Advanced Nursing, vol. 13: 746-751.
Rofman, E. S., Asjubazi, C., & Fant, E. 1980, "The Prediction of Dangerous Behaviour in
Emergency Civil Commitment", American Journal of Psychiatry, vol. 137:1061-1064.
Rogers, P., Watt, A., Gray, N. S., MacCulloch, M., & Gournay, K. 2002, "Content of
command hallucinations predicts self-harm but not violence in a medium secure unit",
Journal of Forensic Psychiatry., vol. 13, no. 2, pp. 251-262.
Rogers, R., Ciula, B., & Cavanaugh, J. L. 1980, "Aggressive and socially disruptive
behaviour among maximum security psychiatric patients", Psychological Reports, vol.
46(291-294).
Roitman, G., Orev, E., & Schreiber, G. 1990, "Annual rhythms of violence in hospitalized
affective patients: correlation with changes in the duration of the daily photoperiod", Acta
Psychiatrica Scandinavica., vol. 82, no. 1, pp. 73-76.
Roper, J. M. & Anderson, N. L. R. 1991, "The interactional dynamics of violence part 1: An

Acute Psychiatric Ward", Archives of Psychiatric Nursing, vol. 5(4): 209-215.
Rosenthal, T. L., Edwards, N. B., Rosenthal, R. H., & Ackerman, B. J. 1992, "Hospital
violence: site, severity, and nurses' preventive training", Issues in Mental Health Nursing,
vol. 13, pp. 349-356.
Roy, S., Herrera, J., Parent, M., & Costa, J. 1987, "Violent and nonviolent schizophrenic
patients: Clinical and developmental characteristics.", Psychological Reports, vol. 61, pp.
855-861.
Ruben, I., Wolkon, G., & Yamamoto, J. 1980, "Physical attacks on psychiatric residents by
patients", Journal of Nervous Mental Disorders, vol. 168, pp. 243-245.
Rutter, S., Gudjonsson, G., & RabeHesketh, S. 2004, "Violent incidents in a medium secure
unit: The characteristics of persistent perpetrators of violence", Journal of Forensic
Psychiatry & Psychology., vol. 15, no. 2, pp. 293-302.
Ruzic, K., Franciskovic, T., Sukovic, Z., Zarkovic-Palijan, T., Buzina, N., Roncevic-Grzeta,
I., & Petranovic, D. 2008, "Predictors of aggressiveness in schizophrenic patients treated in
inpatient forensic institutions", Collegium Antropologicum, vol. 32, no. 2, pp. 331-337.
Ryan, J. & Poster, E. 1989, "The assaulted nurse: Short-term and long-term responses",
Archives of Psychiatric Nursing, vol. 3, no. 6, pp. 323-331.
Schwartz, T. & Park, T. 1999, "Assaults by patients on psychiatric residents: A survey and
training recommendations", Psychiatric Services, vol. 50, no. 3, pp. 381-383.
Secker, J., Benson, A., Balfe, E., Lipsedge, M., Robinson, S., & Walker, J. 2004,
"Understanding the social context of violent and aggressive incidents on an inpatient unit",
Journal of Psychiatric and Mental Health Nursing, vol. 11, pp. 172-178.
Serper, M., Beech, D. R., Harvey, P. D., & Dill, C. 2008, "Neuropsychological and symptom
predictors of aggression on the psychiatric inpatient service", Journal of Clinical &
Experimental Neuropsychology: Official Journal of the International Neuropsychological
Society, vol. 30, no. 6, pp. 700-709.
Serper, M. R., Goldberg, B. R., Herman, K. G., Richarme, D., Chou, J., Dill, C. A., &
Cancro, R. 2005, "Predictors of aggression on the psychiatric inpatient service",
Comprehensive Psychiatry., vol. 46, no. 2, pp. 121-127.
Shader, R., Jackson, A., Harmatz, J., & et al 1977, "Patterns of violent behaviour among
schizophrenic patients", Diseases of the Nervous System, vol. 38, pp. 13-16.
Shepherd, M. & Lavender, T. 1999, "Putting aggression into context: An investigation into
contextual factors influencing the rate of aggressive incidents in a psychiatric hospital",
Journal of Mental Health. , vol. 8, no. 2, pp. 159-170.
Sheridan, M., Henrion, R., Robinson, L., & Baxter, V. 1990, "Precipitants of violence in a
psychiatric inpatient setting", Hospital and Community Psychiatry, vol. 41, no. 7, pp. 776-
780.
Sjostrom, N., Eder, D. N., Malm, U., & Beskow, J. 2001, "Violence and its prediction at a
psychiatric hospital", European Psychiatry: the Journal of the Association of European
Psychiatrists., vol. 16, no. 8, pp. 459-465.
Smith, C. & McKay, L. 1965, "The open psychiatric ward and its vicissitudes", American
Soares, J. & Lawoko, S. 2000, "The nature, extent and determinants of violence against
psychiatric personnel", Work & Stress, vol. 14, no. 2, pp. 105-120.
Soliman, A. & Reza, H. 2001, "Risk factors and correlates of violence among acutely ill adult
psychiatric inpatients", Psychiatric Services, vol. 52, no. 1, pp. 75-80.
Spokes, K., Bond, K., Lowe, T., Jones, J., Illingworth, P., Brimblecombe, N., & Wellman, N.
2004, "HOVIS-The Hertfordshire/Oxfordshire Violent Incident Study", Journal of
Psychiatric and Mental Health Nursing no. 9, pp. 199-209.
Steinert, T., Wolfle, M., & Gebhardt, R. P. 2000, "Measurement of violence during in-patient
treatment and association with psychopathology.", Acta Psychiatric Scandinavica, vol. 102,
pp. 107-112.
Steinert, T., Wiebe, C., & Gebhardt, R. P. 1999, "Aggressive behavior against self and others
among first-admission patients with schizophrenia", Psychiatric Services., vol. 50, no. 1, pp.
85-90.
Steinert, T., Eisele, F., Goeser, U., Tschoeke, S., Uhlmann, C., & Schmid, P. 2008,
"Successful interventions on an organisational level to reduce violence and coercive
interventions in in-patients with adjustment disorders and personality disorders", Clinical
Practice & Epidemiology in Mental Health, vol. 4, no. 27.
Stockman, C. L. J. & Heiber, P. 1980, "Incidents in hospitalised forensic patients",

Victimology, vol. 5(175-192).
Sullivan, C. & Yuan, C. 1995, "Workplace assaults on minority health and mental health care
workers in Los Angeles", American Journal of Public Health, vol. 85, no. 7, pp. 1011-1014.
Swinton, M. & Hopkins, R. 1996, "Violence and Self-injury", Journal of Forensic

Tam, E., Engelsmann, F., & Fugere, R. 1996, "Patterns of violent incidents by patients in a
general hospital psychiatric facility", Psychiatric Services, vol. 47, no. 1, pp. 86-88.
Tardiff, K. & Koenigsberg, H. 1985, "Assaultive behaviour among psychiatric outpatients",

American Journal of Psychiatry, vol. 142, pp. 960-963.
Tardiff, K. 1983, A survey of assault by chronic patients in a state hospital system in Lion, J.
and Reid, W.(Eds) Assaults Within psychiatric Facilities. Orlando: Grune and Stratton..
Thomas, C., Bartlett, A., & Mezey, G. C. 1995, "The extent and effects of violence among
psychiatric in-patients", Psychiatric Bulletin, vol. 19, pp. 600-604.
Thomas, M., Ekland, E., Griffin, M., & et al 1990, "Intrahospital relocation of psychiatric
patients and effects on aggression", Archives of Psychiatric Nursing, vol. 4, pp. 154-160.
Tobin, M., Lim, L., & Falkowshi, W. 1991, "How do we manage violent behavior", British
Journal of Clinical and Social Psychiatry, vol. 8, no. 1, pp. 19-23.
Torpy, D. & Hall 1993, "Violent incidents in a Secure Unit", Journal of Forensic Psychiatry,
vol. 4, no. 3, pp. 517-544.
Troisi, A., KUstermann, S., Di-Genio, M., & Siracusano, A. 2003, "Hostility during
admission interview as a short term predictor of aggression in acute psychiatric make
inpatients", Journal of Clinical Psychiatry, vol. 64, pp. 1460-1464.
Turns, D. & Gruenberg, E. 1973, "An attendant is murdered: The state hospital responds",
Psychiatric Quarterly, vol. 47, no. 4, pp. 487-494.
Tyrer, P., Cooper, S., Herbert, E., Duggan, C., Crawford, M., Joyce, E., Rutter, D.,
Seivewright, H., O'Sullivan, S., Rao, B., Cicchetti, D., & Maden, T. 2007, "The
Quantification of Violence Scale: A simple method of recording significant violence",
International Journal of Social Psychiatry, vol. 53, no. 6, pp. 485-497.
Uzun, O. Perceptions and Experiences of Nurses in Turkey about Verbal Abuse in Clinical
Settings. Journal of Nursing Scholarship 35, 81-85. 2003.
Ref Type: Generic
Vanderslott, J. 1998, "A study of violence towards staff by patients in an NHS Trust
Hospital", Journal of Psychiatric and Mental Health Nursing, vol. 5, pp. 291-298.
Waldheter, E. J., Jones, N. T., Johnson, E. R., & Penn, D. L. 193, "Utility of social cognition
and insight in the prediction of inpatient violence among individuals with a severe mental
illness", Journal of Nervous & Mental Disease. no. 9, pp. 609-618.
Walker, Z., Seifert, R., & Walker, Z. 1994, "Violent Incidents in a Psychiatric Intensive Care
Unit", British Journal of Psychiatry, vol. 164: 826-828.
Watts, D. 2003, "The prediction of violence in acute psychiatric units", International Journal
of Forensic Mental Health, vol. 2, pp. 173-180.
Wazome, E. G. 1988, "A study of aggressive and violent behaviour among a group of
psychiatric in-patients in Kenya", East African Medical Journal, vol. 65, no. 6, pp. 360-365.
Weizmann-Henelius, G. & Suutala, H. J. O. 2000, "Violence in a Finnish forensic psychiatric

hospital", Nordic Journal of Psychiatry., vol. 54, no. 4, pp. 269-273.
Werner, P. D., Yesagave, J. A., Becker, J. M. T., Brunsting, D. W., & Issacs, J. S. 1983,
"Hostile words and assaultive behaviour on an acute in-patient psychiatric unit", Journal of
Nervous and Mental Disease, vol. 171(385-387).
Whittington, R. 2002, "Attitudes toward patient aggression amongst mental health nurses in
the 'zero tolerance' era: associations with burnout and length of experience", Journal of
Clinical Nursing, vol. 11, pp. 819-825.
Whittington, R. & Higgins, L. 2002, "More than zero tolerance? Burnout and tolerance for
patient aggression amongst mental health nurses in China and the UK", Acta Psychiatr
Scand, vol. 106, no. Suppl. 412, pp. 37-40.
Whittington, R. & Wykes, T. 1989, "Aggression: Invisible injury", Nursing Times, vol. 85,
no. 42, pp. 30-32.
Whittington, R. & Wykes, T. 1991, "Coping Strategies used by staff following assault by a
patient: an exploratory study", Work & Stress, vol. 5, no. 1, p. -37.
Whittington, R. & Wykes, T. 1992, "Staff strain and social support in a psychiatric hospital
following assault by a patient", Journal of Advanced Nursing, vol. 17, pp. 480-486.
Whittington, R. & Wykes, T. 1994, "Violence in psychiatric hospitals: are certain staff prone
to being assaulted", Journal of Advanced Nursing, vol. 19, pp. 219-225.
Whittington, R. & Wykes, T. 1994, "An observational study of associations between nurse
behavior and violence in psychiatric hospitals", Journal of Psychiatric and Mental Health
Whittington, R. & Wykes, T. 1996, "An evaluation of staff training in psychological

techniques for the management of patient aggression", Journal of Clinical Nursing, vol. 5,
pp. 257-261.
Whittington, R. & Wykes, T. 1996, "Aversive stimulation by staff and violence by
psychiatric patients", British Journal of Clinical Psychology, vol. 35, pp. 11-20.
Woods, P., Ashley, C., Kayto, D., & Heusdens, C. 2008, "Piloting violence and incident
reporting measures on one acute mental health inpatient unit", Issues in Mental Health
Nursing, vol. 29, no. 5, pp. 455-469.
Wynn, R. & Bratlid, T. 1998, "Staff's experiences with patients' assaults in a norwegian
psychiatric university hospital: A pilot study", Scandinavian Journal of Caring Sciences.,
vol. 12, no. 2, pp. 89-93.
Yassi, A., Tate, R., Cooper, J., Jenkins, J., & Trottier, J. 1998, "Causes of staff abuse in
health care facilities. Implications for prevention", American Association of Occupational
Health Nurses (AAOHN) Journal, vol. 46, pp. 484-491.
Yesavage, J., Werner, P., Becher, J., & et al 1981, "Inpatient evaluation of aggression in
psychiatric patients", Journal of Nervous Mental Disorders, vol. 169, pp. 299-302.
Yesavage, J. A. 1983, "Bipolar Illness: Correlates of dangerous in-patient behaviour", British

Yesavage, J. A. 1983, "Inpatient violence and the schizophrenic patient", Acta Psychiatrica
Scandinavica, vol. 67, pp. 353-357.
Yusuf, F., Hendriks, M. M., Eng, T. S., Kandasamy, R., R, Selvarani, S., & Huang, P. H.
2006, "The impact of verbal abuse on staff working in the psychiatric wards", Singapore
Nursing Journal, vol. 33, no. 3, pp. 31-36.
Other references
Abderhalden, C., Needham, I., Miserez, B., Almvik, R., Dassen, T., Haug, H. et al. 2004,
"Predicting inpatient violence in acute psychiatric wards using Broset-Violence-Checklist: a
multicentre prospective cohort study", Journal of Psychiatric and Mental Health Nursing,
vol. 11, pp. 422-427.
Coid, J., Kahtan, N., Gault, S., Cook., A., Jarman, B. 2001, "Medium secure forensic
psychiatric services: comparison of seven English health regions", British Journal of
Fazel, S., Gulati, G., Linsell, L., Geddes, J.R., Grann, M. 2009, Schizophrenia and Violence:
Systematic Review and Meta-Analysis. PLoS Medicine, vol 6(8): e1000120.
Higgins, J., Thompson S, Deeks, J., Altman, D.G. 2003, "Measuring inconsistency in meta-
analyses", British Medical Journal, vol. 327, pp. 557-560.
Mueser, K. T., Drake, R. E., Wallach, M.A. 1998, "Dual diagnosis: a review of etiological
theories", Addictive Behaviors, vol. 23, pp. 717-734.
Ogloff, J. R. P. & Daffern, M. 2006, "The Dynamic Appraisal of Situational Aggression: An

Instrument to Assess Risk for Imminent Aggression in Psychiatric Inpatients", Behavioral
Sciences & the Law, vol. 24, pp. 799-813.
Perera, R. & Heneghan, C, 2008, "Interpreting meta-analysis in systematic reviews",
Evidence Based Medicine, vol. 13, pp. 67-69.
Royal College of Psychiatrists 2007, Healthcare Commission National Audit of Violence

2006-7. London: Royal College of Psychiatrists.

Inpatient Violence and Aggression: A Literature Review

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Inpatient violence and

Report from the Conflict and Containment

A matrix (in Excel) was constructed with a number of headings including:

3.1 The studies reviewed

3.2 Overall incidence

A meta-analysis (with random effects) was conducted as an alternative method of

Figure 1: Distribution for patient based rate

0 500 1000 1500 2000

Figure 3: Distribution of events per 100 admissions per month

0 500 1000 1500 2000

Figure 5: Distribution of events per 100 occupied bed days

Kernel density estimate

Table 2: Ranked mean violence rates by country (high to low)

Rates of violence would also be expected to be influenced by the type of psychiatric

Table 3: Rates of violence by setting

Forensic Acute Psych hosp

Figure 8: Mean event based % by country and setting

Forensic Acute Psych hosp

Figure 9: Mean events per 100 admissions per month

Forensic Acute Psych hosp

Forensic Acute Psych hosp

Table 4: Definitions of violence/aggression

The frequencies enabled four groups of studies to be compared: physical aggression,

Table 5: Rates of violence by definition

Table 6: Rates of violence by inclusion/exclusion of verbal aggression

3.5 Study methodology

Table 7: Rates by methodology

3.7 Repeated violence

Thirty-one studies provided enough information to calculate the proportion of violent

Figure 13: Incidents per violent patient by setting

3.8 Physical violence

Comparison of patient based rate by setting revealed no significant difference

3.9 Staff surveys of violence

Nurses Psychiatrists Mix

Four studies reported international comparisons. UK nurses experienced higher rates

3.11 Points the City model has missed

A small minority of patients were found to be responsible for multiple episodes of

Lessons for future research

4.1 The studies reviewed

4.2 Thematic analysis

A thematic analysis of the antecedent data produced 59 distinct lower-level themes

PATIENT-PATIENT STAFF-PATIENT PATIENT EXTERNAL / STRUCTURAL PATIENT PATIENT

Table 2: Patient-patient interactions as recorded antecedents of violent incidents

Competition Two or more patients engaged in some 1 1.40% -

Reaction to sexual One patient approaches another patient in 1 1.40% -

Victim doing something Victim of aggression/violence was 1 1.40% -

Retaliation The assailant retaliated on another patient 2 2.80% -

Patient victim The assailant became violent/aggressive 1 1.40% -

Teased/bugged The assailant was being teased or bugged 4 5.60% -

Miscommunication* A communication problem between patient 5 6.90% -

Another lower-level patient-patient interaction antecedent of violence was patient engaged

Five studies reported the antecedent miscommunication. This included a retrospective

The final lower-level patient-patient interaction theme was unspecified patient-patient

1. Limiting patients freedoms

SOAS/R tool, 9/19 used

studies within forensic

ECT The use of electro-convulsive therapy 1 1.40% -

Intervening on fight Staff intervening on a fight or argument between two 3 4.20% -

studies within inpatient acute

Searching patients Staff searching patients for items 2 2.80% -

Negative staff Staff working with a negative attitude 1 1.40% -

Staff victim A characteristic of the staff victim triggered the 1 1.40% -

Patient engaged in Patient engaged in an activity 1 1.40% -