Nursing staff in psychiatric wards and A&E are most at risk of verbal and/or physical attack from aggressive patients. A new study, published last month in the Australian Healthcare Association journal, Australian Health Review, says training staff in aggression avoidance techniques is not enough.
The study by Queensland University psychiatrist Tom Meehan looked into different approaches to managing violent behaviour within mental health facilities. Several mental health units attached to the Park, Centre for Mental Health in Brisbane took part in the study, which covered a seven year period.
Meehan is Director, Service Evaluation & Research at the Park, and Senior Lecturer in the Department of Psychiatry at Queensland University. He has a background in nursing and understands the pressures and stresses nurses face. He trained as a general nurse and psychiatric nurse in Ireland before moving to Sydney in 1987, and gained a Master of Public Health Degree from the University of New South Wales in 1993 and a Master of Social Science from the University of Queensland in 1998.
As chief-investigator for a number of large-scale research and evaluation studies, Meehan has accumulated over A$1.5 million in research funding the past 10 years. He has published widely and provided keynote papers at conferences in Australia and overseas. He says it’s important to have research on matters that affect nurses performed by nurses.
“The prevention of violence involves a complex interaction between the client, their social structure and their environment,” Meehan says.
One of the factors contributing to increasing levels of aggressive behaviour in patients is the age of patients awaiting treatment in A&E, or receiving treatment in mental health facilities. Patients under 35 seem to exhibit higher levels of aggression, less patience, and less respect for authority. This is not limited to young men, he says; young women are also becoming increasingly aggressive, and more demanding.
Another aspect is the persistent under-reporting by staff of aggressive incidents, treating violence as a normal part of the working life. Most acts of aggression are verbal, or simple acts such as pushing or shoving. Real violence is comparatively minor. For many nurses in psychiatric wards or in A & E departments, constant verbal abuse becomes part of the work environment, and more resilient nurses become immune to it.
“However, continuous verbal assaults can have a major impact on a person’s self-esteem, and their ability to perform in their job,” Meehan says.
“While with patients waiting in A&E, abuse stems from impatience and a lack of understanding how the triage and queuing system works, patients in mental health facilities will often look for ways in which to needle staff and upset them.”
This is where staff support is vital. Under the multi-strategy approach, staff who have been assaulted – physically or verbally – are assigned a mentor to provide them with peer support over the next few days. The mentor also assists the victim to report the incident.
A factor in under-reporting is the expectation by ward staff that management is not serious about dealing with aggression. “If management doesn’t take a stand, then reporting is seen as just a paper exercise, and only those who are less resilient will make the effort to report incidents.”
“Management needs to take an active role in dealing with violence, and training is only one component – it doesn’t solve the problem. It needs to deal with the aggression immediately, and also on a long-term basis.”
Over the seven-year period of the study, reported violent incidents within stand-alone facilities resulting in injury were significantly reduced when a multi-strategy approach was used.
The study dealt specifically with mental health units, but Meehan says many of the strategies could apply equally well in A&E.
“A multi-strategy approach contrasts with traditional strategies that focus solely on staff training,” he says.
“Staff training on its own may have a limited role in reducing aggressive behaviour.
“What we’ve shown through this study is that facilities need to address aggressive behaviour through a combination of tactics rather than relying on the implementation of individual strategies.”
Although there was no change in aggressive patient behaviour, there was a marked decrease in resultant staff injuries.
“This demonstrates the effectiveness of the methods as part of a multi-strategy program in controlling aggressive behaviour,” he says.
Risk assessment is an important strand of the multi-strategy approach. One strategy being discussed is a system for identifying repeat offenders. People who consistently turn up at A&E departments in Queensland Health under the influence of alcohol or drugs could have their records flagged as at risk of aggression, so staff are prewarned to be careful. However, there are ethical and privacy issues to be considered before this could be implemented.
Feedback to staff on the level of aggression within the unit is vital,” Meehan says. “Staff are entitled to know that a person has a previous record of violence; the unit manager needs to make staff aware of the situation.
“Violence in a mental health unit is related to disruption to the normal make-up of the ward. Factors such as staff on sick leave, casual staff, medication errors, and injuries and falls both of patients and staff members are all indicators of rising levels of aggression.
“The unit manager needs access of all this data to see how the unit is travelling; if there is a ‘bump’ in the data, the manager needs to be pro-active to make the environment as peaceful as possible.”
The multi-strategy approach developed by Meehan and co-author Dr Terry Stedman, Director of Clinical Services at The Park consists of support, risk assessment and monitoring as well as staff training:
Staff training: intensive workshops in Professional Assault Response Training and education and training in areas relating to the management of violence.
Staff support program: specially trained volunteer staff who act as mentors in the case of a violent or aggressive incident.
Risk assessment tools: including a checklist of common behavioural and environmental factors linked to aggressive situations to assess the patient and predict the potential for aggression.
Computerised incident monitoring system: for accumulation of incident reports and data of violent or aggressive situations.