The findings of our study provide a valuable insight into the attitudes of clinical staff respondents toward the contentious issue of the causes and management of aggression in acute old age psychiatry inpatient settings. In relation to the causes, overall, the respondents tended to disagree that internal or direct patient related factors were contributing influences. However, they perceived aggression was related to mental illness, and some patients were more susceptible to aggression than others. These findings suggest that while the respondents were less likely to attribute blame to patients for aggression, they perceived those with certain conditions were more susceptible to these forms of behaviours. This view is consistent with some literature suggesting patients with persecutory delusions [5, 16] and impulsivity  are particularly prone to aggression; the risk is greater during the acute phase of psychotic illness; and thought disorder, impairment of neuropsychological functioning, disorganized behaviour and substance misuse, are lesser contributing factors [2, 13, 43–45].
The respondents in the current study also indicated socio-demographic influences; in particular, cultural consideration had contrasting effects on the onset of aggression. They felt patients from some cultural backgrounds were more susceptible to aggression than others, and cultural misinterpretations between staff and patients contributed to this behaviour. There are contrasting findings in the limited psychiatric literature examining the influence of cultural background on aggression. Depp  found black patients are overrepresented in the striking role whereas white patients are more likely to be in the non-striking role. However, James et al.  reported there were no statistical differences between the cultural backgrounds of violent and non-violent patients. Therefore, in the present study cultural misinterpretations may be attributed to poor staff-to-patient interactions [9, 10], which can lead to frustration and this, in turn, increases the likelihood of aggression . They may also be due to cultural misunderstandings wherein some illness related behaviours, such as aggression and loud speech, are perceived as abnormal by clinicians but may be perfectly acceptable within a particular patient’s culture .
The respondents agreed that gender mix of staff on wards was helpful in the prevention of aggression. There are contrasting findings in the literature, however, about the influence of staff gender on patient aggression. Daffern et al. , in a 6-month review of episodes of patient aggression in a forensic psychiatric hospital, found no statistically significant relationship between the gender ratio of staff and aggression. However, a review of ecological factors influencing inpatient psychiatric unit violence, by Hamrin et al. , presented conflicting findings about staff gender and aggression; with some studies concluding male staff were at greater risk of being recipients of violence, whereas other studies reported females staff were the most common recipients of violence.
The respondents in the present study tended to agree that external and situtational/interactional (or situational and contextual) influences contributed to the onset of aggression, including the use of restrictive environments such as locked wards. They also perceived if the physical environment was improved patients would be less prone to aggression. These findings can be explained by external and situational/interactional influences, such as restrictive environments, which increase the likelihood of frustration and the possibility of aggression . The findings also accord with other studies that report the physical characteristics of the ward environment, such as irritating noise, lack of privacy, restriction in liberty [12, 43, 44, 49], and lack of activities , contribute to aggression.
There was agreement in the current study that poor staff-to-patient communication contributed to the onset of aggression. Whittington and Wykes , in a United Kingdom study of inpatient aggression, also reported the influence of aversive stimulation by staff, such as physical contact, frustration, demands patients participate in activities, and critical comments. It can also be extrapolated that poor staff-to-patient communication leads to frustration [1, 9, 10], which, in turn, may culminate in patient aggression.
Regarding the management of patient aggression, the respondents were in agreement this behaviour could be managed more successfully, and a person-centred approach could be used more often as well as judicious use of medication. These findings can be explained, whereby external stimuli, such as person-centred and careful medication-use techniques [10, 11], could have a moderating influence in reducing the likelihood of aggression .
The findings of the present study also indicated restraint and seclusion were used more than necessary in the management of aggression, and there was disagreement about whether the practice of seclusion should be stopped. The preference by staff to retain the option to use seclusion has also been reported in United Kingdom studies by Duxbury and Whittington  and Foster et al. . Possible explanations for the somewhat contradictory findings in the current study are person-centred and pharmacological approaches are perceived as insufficient to deal with all instances of aggression. Another explanation is staff support for these containment practises is affected adversely by workplace situational and contextual and broader cultural influences and is resistant to change. To illustrate, support for such practises may be lower in countries where these approaches are uncommon but higher in countries where they are adopted more often, such as Australia [21, 23, 52]. Furthermore, the current study’s findings highlight a dichotomy between government [25, 26], service user [19, 52] and carer groups  that advocate the abolition of seclusion and the views of coalface face clinicians confronted with this type of challenging behaviour.
Limitations and strengths
While a representative sample of 78% of clinical staff was obtained, the data may not accurately reflect the views of all such staff because those working at weekends and at night were not included. This could be addressed in a future study by recruiting respondents throughout the 24-hour, 7-day spectrum. Next, as the sample was derived from three inpatient units within a single mental health service, this limits the ability to infer from this sample to the general population of clinical staff working in other acute old age psychiatry inpatient units. Recruiting respondents from a wider range of mental health services could rectify this in a subsequent study. Finally, the sample only included the views of clinical staff; current and former inpatients were considered for inclusion but were not deemed well enough by clinical staff to provide consent.