Volume 196 - Issue 3
Patient aggression: a serious issue requiring a dedicated organisational response
Author: Brett McDermott
Med J Aust 2012; 196 (3): 154-155. || doi: 10.5694/mja12.10112
Published online: 20 February 2012
Published online: 20 February 2012
Staff safety is improved by clear procedures for managing abuse and assault. Hopper and colleagues describe a scenario familiar to many hospital clinicians and managers: staff reports of verbal abuse and physical assaults from patients.This is often in an organisational context of scarce reliable data about the phenomenon, an ad-hoc management response and no specific training of staff to manage aggression....
Staff safety is improved by clear procedures for managing abuse and assault
Hopper and colleagues describe a scenario familiar to many hospital clinicians and managers: staff reports of verbal abuse and physical assaults from patients.1 This is often in an organisational context of scarce reliable data about the phenomenon, an ad-hoc management response and no specific training of staff to manage aggression. Aggression is not defined in the Hopper et al article but it is useful to remember that it is a broad term, inclusive of behaviour that is destructive to self, others and property.2 As with many other behaviours, a therapeutic framework can be applied to aggression. The origin of aggression in children and adolescents is often a developmental failure to regulate impulsivity and behaviour following prejudicial early-life experiences, including exposure to coercive parenting. Aggression is often a feature of a developmental or mental health disorder.3
In the Hopper et al article, a response to aggression is detailed and evaluated. The institutional response included staff attending a two-day training course, the initiation of a “code grey” procedure and a stepped intervention algorithm. A response protocol ensures standardisation of approach and clearly defines the algorithm for the response levels. In some cases, this response may lead to physical and chemical restraint. Hopper and colleagues report that the aggressive individual is not always a patient (he or she may be a visitor), and that the incident may be a single or recurring event. They note heterogeneity in the sites of the aggressive incidents, which reminds us of the importance of environmental factors. For example, Gullick and colleagues reported that about one-third of all seclusions following aggression in a child and adolescent mental health unit occurred between 9 pm and midnight.4
The report of Hopper and colleagues is from a paediatric hospital. The child and adolescent mental health services (CAMHS) sector is much more familiar with aggression; different forms of aggression are frequent reasons for admission. Aggression is a symptom of many child and adolescent presentations, such as oppositional defiant disorder and conduct disorder. Identification of factors for a high risk of aggression has been the subject of research in the CAMHS sector. Risk factors for aggression include diagnoses such as mental retardation.5 A report of Dean and colleagues suggests that pervasive developmental disorder, attention deficit hyperactivity disorder, disruptive behaviour disorders, a past history of aggression, and being on psychotropic medications on admission to hospital were significant factors. Multivariate analysis showed that diagnosis was not a significant variable but a history of aggression and current psychotropic medication use remained significant risk factors for predicting aggressive behaviour in hospital.6 A history of whether the individual is on medication is useful, in that being on psychotropic medication is likely to be a proxy for illness severity, as well as being an indicator that previous non-pharmacological interventions may not have been effective. Psychotropic medication, especially atypical antipsychotic medication for psychotic disorders in adolescents and adults, can lead to improvement in aggressive behaviour. The recent indication for risperidone prescription, for behavioural disturbance in children with subaverage intellectual functioning or mental retardation, can also lead to improvement in aggression. Nevertheless, it is also clear that these medications do not prevent incidents of aggression during an inpatient stay. If prescribed “off label” there is less certainty of a beneficial effect on aggressive behaviour.
Service administrators need to be very clear that staff exposure to patient aggression is associated with staff contemplating resignation.3 Staff feelings of safety at work are related to appropriate organisational responses to patient aggression.7 Given the literature that introduction of behaviour management can significantly reduce aggression in some paediatric settings,8 further research and development in this area is likely to lead to benefits for staff, patients and families. It is reasonable to suggest that investment in aggression management strategies would be cost-effective if it leads to less violence in the workplace, less time off work and higher rates of staff retention.
Competing interests
No relevant disclosures.
References
- Hopper SM, Babl FE, Stewart CE, Woo JW. Aggression management in a children’s hospital setting. Med J Aust 2012; 196: 198-201. 0_i1139877
- Connor DF, Carlson GA, Chang KD, et al. Juvenile maladaptive aggression: a review of prevention, treatment, and service configuration and a proposed research agenda. J Clin Psychiatry 2006; 67: 808-820. 0_i1139879
- Dean AJ, Gibbon P, McDermott BM, et al. Exposure to aggression and the impact on staff in a child and adolescent inpatient unit. Arch Psychiatr Nurs 2010; 24; 15-26. 0_i1139881
- Gullick K, McDermott BM, Stone P, Gibbon P. Seclusion of children and adolescents: psychopathological and family factors. Int J Ment Health Nurs 2005; 14: 37-43. 0_i1139883
- Sukhodolosky DG, Cardona L, Martin A. Characterizing aggressive and noncompliant behaviors in a children’s psychiatric inpatient setting. Child Psychiatry Hum Dev 2005; 36: 177-193. 0_i1139885
- Dean AJ, Duke SG, Scott J, et al. Physical aggression during admission to a child and adolescent inpatient unit: predictors and impact on clinical outcomes. Aust N Z J Psychiatry 2008; 42: 536-543. 0_i1139887
- Martin T, Daffern M. Clinician perceptions of personal safety and confidence to manage inpatient aggression in a forensic psychiatry setting. J Psychiatr Ment Health Nurs 2006; 13: 90-99. 0_i1139889
- Dean AJ, Duke SG, George M, Scott J. Behavioral management leads to reduction in aggression in a child and adolescent psychiatry inpatient unit. J Am Acad Child Adolesc Psychiatry 2007; 46: 711-720. 0_i1139891
Provenance: Commissioned; externally peer reviewed.