Causes of aggression

The causes of aggression in elderly patients with mental health problems are complex and interrelated. Aggression may be attributable to psychosocial-environmental factors or the complex interaction of patients, staff and inpatient unit culture influences [8]. It may be due to the inability of elderly patients with dementia to communicate their needs effectively [9], poor staff-to-patient interactions or the environment of care [9, 10], overcrowding, lack of privacy, lack of activities, weak clinical leadership [11], being denied something [7], and restricting patients’ freedom [12].

There is also some debate that aggression may be due to the elderly person having a pre-morbid personality trait of aggression. Various reviews and studies have concluded, however, that an inconclusive relationship exists between premorbid personality and this behaviour [13, 14]. For instance, a systematic review conducted by Osborne, Simpson and Stokes [14] concluded that 72% of studies detected significant relationships between pre-morbid personality ─ particularly pre-morbid neuroticism ─ and challenging behaviour such as aggression; however, several studies found no relationship. In addition, there is a direct association between patients with Alzheimer’s disease who have a recent history of aggression [15] and childhood behavioural problems.

There are also contrasting reports about a relationship between particular illnesses and aggression. On the one hand, there are claims that aggression is associated with the person’s illness [9]. In particular, positive relationships have been reported between certain symptomatology, such as paranoid delusional thinking [5, 16], impulsivity [17], dementia symptoms [2], depressive symptoms [13], and aggression. In contrast, James et al. [18] found no diagnosis was positively associated with aggression in an acute psychiatric ward.

Restraint and seclusion

When confronted by aggression, clinical staff may use a range of person-centred (e.g., good staff-to-patient communication, distraction, de-escalation) and containment (e.g., restraint, seclusion, medication) measures to manage this behaviour. Two containment approaches ─ restraint and seclusion ─ are examined because there is debate about their use in the literature. Restraint (the restriction of a person’s freedom of movement by physical, mechanical, chemical, and/or emotional means [19]) and seclusion (the sole confinement of a person in a room where the doors and windows are locked [20]) may be used to prevent and manage aggression [21] but they can have adverse effects on elderly patients in old age psychiatry in particular. Both practises are contrary to prominent international recommendations [22], government reports, mental health service policies, service user organisations and scholarly literature, which advocate that as strategies to deal with disturbed behaviour, restraint and seclusion should be used as little as possible or eliminated.

International variation is evident in containment practises, and this is influenced by a range of factors such as concerns about efficacy and patient safety, and broader cultural values [23]. For instance, in the United Kingdom mechanical restraint is not used and is regarded by many nurses to be reprehensible [23]; in Finland, overall, seclusion is used more frequently than mechanical restraint, but there are regional variations in these practises [24]. In Australia, while there are no national data on the use of restraint and seclusion, the reduction and potential elimination of restraint and seclusion practises and adverse events have been a recommendation of the recent National Mental Health Commission [25], and have been identified as one of four key national priority areas for increasing safety and reducing harm in mental health care [26]. In acute old age psychiatry inpatient settings in particular, restraint use has come under increased examination as a consequence of evidence it may be deleterious [26], ineffective, and unnecessary [27]. The overuse of restraint and seclusion is regarded as an early sign of a mental health system under pressure [25].

Research into the use of restraint in elderly people has been conducted in general hospitals [28] and nursing home settings [9, 10, 29]. However, there has been little investigation of the use of these containment practices with elderly persons in old age psychiatry inpatient settings, and the rate and type of restraint use can vary, even within neighbouring units [30]. Furthermore, Cochrane reviews of restraint and seclusion [31] and containment practises [32] have concluded that non-pharmacological approaches to restraint and seclusion are not supported by evidence from controlled studies.

Attitudes toward aggression

The attitudes of clinical staff toward aggression can influence the way they respond to this behaviour [33, 34]. Positive attitudes may influence the adoption of person-centred approaches whereas negative attitudes may contribute to the use of containment measures. Studies undertaken in various settings have provided contradictory findings about the attitudes of staff toward patient aggression. A United Kingdom survey in a high secure hospital, by Pulsford et al. [35], highlighted that staff held a range of attitudes about the causes and management of patient aggression. However, a United Kingdom survey of the attitudes of staff toward aggressive older people with dementia in residential care, by Pulsford et al. [10], noted that this behaviour was attributable to interpersonal problems resulting from unfavourable situational events such as an adverse environment of care and poor interaction with others in the setting. Furthermore, the staff response to aggression was mainly to adopt a person-centred approach rather than measures such as restraint, seclusion and medication. In contrast, a survey of staff attitudes toward patient aggression in dementia facilities in Japan, by Nakahira et al. [36], reported a significant relationship between staff with negative attitudes toward aggressive patients and the use of physical and chemical restraint. Similarly, Duxbury & Whittington [37], in a United Kingdom survey of staff attitudes toward aggression in an acute psychiatric inpatient setting, highlighted that respondents who perceived internal influences on patients contributed to this behaviour, such as the nature of their illness, were more likely to use containment than person-centred methods to manage this behaviour. The implication of possessing negative attitudes toward aggression and adoption of containment measures is these approaches can culminate in adverse health outcomes for elderly patients in particular. For example, a survey and data set analysis of all nursing homes (N = 740) in Pennsylvania in the United States found a significant association between physical restraint use and subsequent deterioration in patients’ cognitive and activities of daily living performance and increased walking dependence [9, 10, 29].

Little research has been carried out into the attitudes of clinical staff toward the causes and management of patient aggression in psychiatry in general [33, 34] and in acute old age psychiatry in particular [2]. In light of the relationship between attitudes toward aggression and the adoption of measures to deal with this behaviour, and the implications for the patient’s wellbeing, the purpose of this study was to examine the attitudes of clinical staff toward the causes and management of aggression in acute old age care psychiatry inpatient settings.

Study design

A survey design was used, incorporating a structured questionnaire.

Sample & setting

A convenience sample of clinical staff was recruited from three locked acute old age psychiatry inpatient units and their associated community outreach teams, in Melbourne, Australia. The units are managed by the same public mental health service, but each is located in separate geographical locations. The units offer mainly single-room accommodation with en suite toilets, and all have common recreational and dining facilities and gardens. Patients aged 65 years and over are admitted directly to the units from the community or residential care for short-term management of an acute phase of mental illness, until they recover enough to be treated in a community-based setting, and are different, therefore, from nursing homes that cater specifically for people with dementia. Medical, nursing and allied health staff provide the care, and the staffing ratios are broadly similar across the units.

The inclusion criterion for staff was clinical staff employees (Unit manager, Registered/enrolled nurses, psychologists, social workers, occupational therapists, psychiatrists) working on day shifts in the respective units. The exclusion criterion was staff working at night and at weekends. Staff received written invitations to participate, and the project was explained to them either at staff meetings or individually. They were given the choice to complete the questionnaire and hand it back to the researcher, or to return it by mail. Almost all chose the former option.

Instrument

The Management of Aggression and Violence Scale (MAVAS) [37–39] was used to assess attitudes toward the causes of, and ways to manage, aggression. It originally contained 27 items, on a four-point Likert scale, ranging from 1 (strongly agree) to 4 (strongly disagree), with the cut-off for agreeing set at 2.5 (A 5-point version of the scale is also available). A low score indicates agreement with a statement. The Scale has undergone psychometric evaluation and has been shown to contain a strong four-factor structure: internal, external and situational/interactional influences on aggression [38]. (i) Internal (n = 5): Aggression is due mainly to factors within the aggressive person (e.g., mental illness or personality); (ii) External (n = 3): Aggression is caused mainly by influences in the person’s physical or social environment (e.g., physical layout of ward, or manner in which the ward is managed by staff); (iii) Situational/interactional (n = 5): Aggression is attributable to factors in the immediate environment, such as the way staff interact with patients; (iv) Approaches to the management of aggression (n = 14): (e.g., use of medications, restraint and seclusion). The most recent version of the instrument, which was used in the present study, contains 30 items; the three additional items focus on cultural/gender issues.

The internal consistency of the instrument has been established in several studies [38–40]. The Cronbach’s alpha in the present study was 0.8. Ideally, Cronbach’s alpha should be above 0.7 [41].

Ethics

Ethical approval to carry out the study was obtained from Melbourne Health Mental Health Research and Ethics Committee. Researchers, who were not employees of the mental health service, undertook recruitment. Return of questionnaires was interpreted as consent.

Statistical analysis

Data analyses were undertaken using the R environment for statistical computing and graphics [42]. Frequencies, percentages, means and standard deviations were used to analyse the socio-demographic characteristics of respondents. Means and standard deviations were used to assess responses to the causes and management of aggression.

Socio-demographic characteristics of participants

Causes and management of patient aggression

The results are presented in two main sections: (i) causes of aggression, and (ii) management of this behaviour.

Causes of aggression

Management of aggression

The findings indicated agreement-to-disagreement that seclusion was one of the most effective ways for dealing with this form of behaviour, restraint and seclusion were sometimes used more often than necessary, and patients were usually restrained for their own safety. Moreover, there was disagreement with the statement that the practice of seclusion should be discontinued.

There was general agreement person-centred alternatives to containment and sedation, such as negotiation and de-escalation, could be used more effectively to prevent and manage aggression. However, there was agreement-to-disagreement about whether or not staff should always intervene in situations when patients were aggressive.

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.