Secondary Logo

Journal Logo

Articles

The effectiveness of interventions in the prevention and management of aggressive behaviours in patients admitted to an acute hospital setting: a systematic review

Kynoch, Kate RN, BN, MN(Intensive Care)1, ; Wu, Chiung-Jung (Jo) RN, BN, MN(Intensive Care), DHlthSc; Chang, Anne M RN, Dip NEd, BEdSt(Hons), MEdSt, PhD, FRCNA1, 2

Author Information
JBI Library of Systematic Reviews: Volume 7 - Issue 6 - p 175-233
doi: 10.11124/jbisrir-2009-187
  • Free

Abstract

Introduction

Background

The widespread problem of aggression and/or violence in the healthcare sector is regularly highlighted and acknowledged not only by healthcare staff at the forefront of this epidemic, but also the media, researchers and healthcare organisations1-5. Although all healthcare professionals are at risk of aggressive interactions with patients, studies show that it is nurses who are most often victim to verbal and physical violence4. Nurses are not only at risk in psychiatric units but also in acute care settings with violence towards nurses being reported across all healthcare areas5.

Nurses perceive and describe aggression in different ways and likewise researchers tend to use such terms as aggression, anger, hostility or violence interchangeably6-8. Since the descriptions of aggression reported in the literature vary considerably, it is difficult to formulate a precise definition of aggression6. However for the purpose of this systematic review, violence and aggression by patients can be generally defined as any incident that puts a healthcare worker at risk and includes: verbal and physical abuse, threatening behaviours, assault by a patient or any type of behaviour that may cause healthcare workers to fear for their safety9.

The types of aggression and abuse by patients that nurses experience in the workplace is extensive10. The most prevalent form of aggression cited in the literature in all healthcare settings is verbal1,5,11,12, with results from these studies indicating 68% to 96% of nurses having faced verbal abuse at some stage in their career. In contrast, the range of physical aggression or violence experienced by nurses reported in a study by O'Connell et al. included; "being grabbed, punched, kicked, pushed, pinched, scratched, spat on, bitten, chased, stabbed with scissors, swung at, urinated/defaecated on or having their hair pulled" (p. 608)13. In addition to actual violence, the threat of violence is also a significant workplace hazard for nurses14. Although not as frequently experienced as verbal abuse, physical aggression and/or violence poses greater risks to nurses10 with reports ranging from 13% to 21%15, 16.

Registered nurses in the acute care setting are often expected to care for aggressive and/or violent patients with little knowledge and skill regarding appropriate and effective techniques for dealing with acts of aggression4. The effects of such acts of violence and aggression on healthcare staff can be considerable6. Victims of aggression and/or violence often experience feelings associated with post-traumatic stress6, anxiety17, general psychological health18, fatigue6, sleep disturbances6 and increased smoking and alcohol consumption19. A study by O'Connell et al.13 found that nurses, after experiencing either verbal or physical aggression, most frequently reported feeling angry or emotionally hurt and often had increased sick leave. The resulting cost in resources usually extends beyond the individual to the organisation20.

Management of patient aggression

Abundant literature exists on the management of patients who exhibit aggressive traits, including interventions aimed at both patients and nursing staff. The majority of this information relates to those patients admitted to psychiatric facilities. However several studies have been conducted in acute care settings.

Staff education and training

A number of studies have found significant benefits from education and training programs for healthcare workers in both psychiatric and acute care settings21-25. Education sessions for staff to develop skills and increase confidence for managing and dealing with acts of aggression from patients, through attendance at workshops and training days, have been found to increase staff self-efficacy26. The majority of these studies were aimed at psychiatric nurses. Very little research has been done to understand the factors associated with nursing staff response to an aggressive and/or violent patient.

Pharmacological management

Traditionally, aggressive and/or violent patients were physically restrained to prevent injury to themselves and/or healthcare staff, however more recent research has found that chemical restraint was not only more effective but also more humane than physical restraint27. In many healthcare settings, medications are considered a less invasive alternative to the use of physical restraint for patients exhibiting aggressive and/or agitated behaviours, a practice that is often referred to as "chemical restraint"28. A number of studies have found the use of medications such as droperidol, haloperidol, midazolam and lorazepam effective in sedating aggressive and violent patients27, 29-33. As yet, there is no consensus among clinicians or policy makers whether the use of such medications is a form of coercion or a form of patient-focused intensive care28.

Restraint and seclusion

Nurses often restrain patients for a variety of reasons including: aggressiveness, wandering behaviours and confusion34. The use of physical restraints to manage agitated and aggressive patients is often routine practice in some acute hospital settings such as emergency departments and critical care units35. Additionally, the use of seclusion is a common intervention used in the mental health setting for violent patients and can be viewed as a form of physical restraint36. While the literature on physical restraints advocates for reduced restraining practises across all healthcare institutions, it appears this is still a commonly used intervention for managing patient aggression and violence25, 35, 37, 38.

Predicting patient aggression and/or violence

Several studies have investigated whether it is possible to predict inpatient violence from patients admitted to mental health settings39-41. An article by Steinert, concluded that clinical predictions of a patient's violence potential is better than chance but limited by the effects of therapeutic interventions in psychiatric patients40. Kling et al. retrospectively examined the effectiveness of a screening tool for use in the acute care setting to identify potentially aggressive and/or violent patients42. This study suggested that the use of such a tool on patients was effective in identifying potentially violent and aggressive patients when it was used according to hospital protocol. Further research evaluating the potential use of these tools in the acute care setting is warranted.

Music therapy

There has been limited research into the use of music therapy in managing aggressive and agitated behaviours of patients in the acute care setting however several studies have been set in nursing homes. The purpose of one such study by Clark et al. was to examine the effects of recorded, preferred music in decreasing occurrences of aggressive behaviour among individuals with dementia during bathing episodes43. The results indicated a significant decrease in aggressive behaviours during the music condition. Additionally, caregivers frequently reported improved affect and a general increase in cooperation with the bathing task43.

A further study comparing individualised versus classical music for nursing home residents with behavioural problems found a reduction in agitated and/or aggressive behaviours for both types of music therapy, but concluded that music was more effective when individualised to patients44. Despite the reported benefits of music therapy in the aged care setting, studies in the acute care setting are limited.

Multiple interventions

Although the use of multiple interventions may be likely to decrease the incidence of aggressive and/or violent acts towards healthcare staff, only one study was found that investigated the combination of several interventions. Needham et al. investigated the use of systematic aggression risk assessment, in combination with a standardised training course in aggression management to reduce the frequency and severity of aggressive incidents in two Swiss psychiatric wards45. The study concluded that a systematic risk assessment and a training course may assist in reducing the incidence of aggressive incidents however further investigations would be beneficial.

De-escalation of aggression and/or violence

De-escalation is a valuable intervention often used by mental health nurses to help counter the growing problems of aggression and violence46. Cowin et al. define de-escalation as a gradual resolution of a potentially violent and/or aggressive situation through the use of verbal and physical expressions of empathy, alliance and non-confrontational limit setting that is based on respect46. However the confidence, knowledge and skills needed to de-escalate a potentially aggressive and/or violent situation require adequate training and experience, and not all nurses feel confident using de-escalation techniques46. This is of particular importance for areas such as emergency departments where de-escalation may be especially necessary.

De-escalation is not a new tool in the mental health-care setting, with a study by Cowin et al.46 finding an educative program aimed at renewing psychiatric nurses' knowledge and skills in de-escalation to be valuable and of considerable benefit to those nurses who were transient within the workplace, such as casual and agency nurses46. This technique may also have benefits for nurses working in acute care settings, however further research studies are required.

While the use of interventions such as de-escalation, chemical and physical restraint and prediction are commonly used techniques in psychiatric facilities, limited studies were found that investigated interventions for patient aggression and violence in the acute care setting. Therefore this review aims to analyse the current evidence on what are the most effective interventions for preventing and managing aggressive behaviours in patients admitted to an acute hospital setting.

Review Methods

Objectives

The purpose of this systematic review was to establish best practice in the prevention and management of aggressive behaviours in patients admitted to an acute hospital setting.

More specifically, the objectives were to identify;

  1. What are the most effective interventions in the prevention of aggressive behaviours in patients admitted to an acute hospital setting?
  2. What are the most effective interventions in the management of aggressive behaviours in patients admitted to an acute hospital setting?

Criteria for considering studies for this review

Types of studies

This review selected studies published from 1990-2007 based on the retrieval of previous studies for the background. Although there were studies as far back as 1985, the review panel decided to concentrate this systematic review on more current research due to the increased attention on this topic and because of the more recent increase in rigour of research and standards for publication.

This review considered any randomised controlled trials (RCT) that evaluated the effectiveness of interventions in the prevention and management of patients who exhibit aggressive behaviours in an acute hospital setting. In the absence of RCT's, other research designs such as non-randomised controlled trials, descriptive, observational and before and after studies were considered for inclusion in the narrative summary to enable the identification of current approaches and possible future strategies for minimising the risks associated with aggressive behaviours in acute care areas. Studies that were undertaken in any country were retrieved however due to limited resources only those studies reported in English were included in the review.

Types of participants

This review included all studies with adult patients who exhibited aggressive behaviours and were admitted to an acute hospital setting.

Types of aggressive behaviours included;

  • Verbal abuse
  • Non-verbal abuse
  • Physical violence
  • Threatening behaviours
  • Assault

Studies with acute care nurses as the primary participants which investigated interventions to prevent or minmise patient aggression and/or violence were also included in the review.

Types of interventions

Studies were eligible for inclusion if the intervention evaluated in the study could be used by nurses in the acute setting to prevent or manage any acts of aggression and/or violence from patients in their care. All studies evaluating one or more of the following interventions were included in the review:

  • Administration of "as required" prescribed medications
  • Physical restraint
  • Seclusion
  • Clinician behaviours including:
    • Verbal communication techniques
    • Use of body language
    • Prevention and recognition strategies (e.g. use of risk assessment tools)
    • Staff attitudes, knowledge and skills
  • Environmental controls (e.g. minimising light, noise and conversations)
  • Setting of limits for patients to follow
  • Increase in staff numbers

Types of outcome measures

The primary outcome of interest was patient aggression. Other outcomes for inclusion were:

  • Staff injuries
  • Staff confidence
  • Staff knowledge
  • Staff attitudes
  • Staff skill level
  • Stress/anxiety levels among staff
  • Patient injuries
  • Early detection of aggressive behaviours

Criteria for exclusion of studies for this review

In addition to excluding studies that were not reported in English this review also excluded studies with patients;

  • <18 years old
  • Admitted to a psychiatric setting

Search strategy

The aim of the search strategy was to retrieve all published and unpublished studies relating to interventions used to prevent and manage aggressive behaviours in patients admitted to an acute hospital setting. This review utilised a three-step search strategy. Before commencing the database searches, a preliminary search of CINAHL and MEDLINE databases was conducted to identify keywords contained in the titles and abstracts of papers and MeSH headings or subject descriptor terms used for each database. The second stage of searching involved an initial search of the databases, conducted by a qualified health librarian, using the keywords and thesaurus terms that were identified from the title and abstracts of relevant papers.

The databases searched included; MEDLINE, CINAHL, psycINFO, Health source, Web of Science, EMBASE, the Cochrane Library including DARE (Database of abstracts of reviews of effects) and Pubmed. Table 1 details the results retrieved from each database. The specific search strategies used for each database, including all the search terms, are presented in Appendix 1. The search for unpublished studies also included grey literature and dissertation abstracts. The grey literature websites searched are listed in Appendix 2.

Table 1
Table 1:
Results for search of databases

In the final step of the search strategy, hand-searching was undertaken of the reference lists of included studies. References were considered for inclusion based on the title. The full text of the paper was then retrieved if the article appeared relevant. References identified from the search of electronic databases were entered into a bibliographic software package (EndNote).

Methodological quality

The relevance of papers selected for retrieval was assessed by two independent reviewers for adherence to the inclusion criteria. Additionally, the methodological quality of those studies that met the inclusion criteria were critically appraised by the two reviewers using the standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics: Assessment and Review Instrument (JBI-MAStARI) (Appendix 3). Any disagreements that arose between the reviewers were resolved through discussion with a third reviewer. The reviewers were not blinded to the authorship of the studies.

Data Collection and analysis

Two reviewers independently carried out data extraction from the included studies. Data was extracted from the studies using the standardised data extraction tool from the Joanna Briggs Institute Meta Analysis of Statistics: Assessment and Review Instrument (JBI-MAStARI) package (Appendix 4). Where there was disagreement between the reviewers, a third reviewer was consulted. A meta-analysis for this review could not be undertaken, as there was considerable variation in the measured outcomes in the trials identified, therefore data is presented in narrative summary.

Results

The search strategy identified a total of 1613 records from all databases searched. All articles were imported into the reference manager software "Endnote" and following the removal of duplicates, 954 articles remained. All 954 records were then assessed by two reviewers for potential relevance and inclusion in the review from title and abstract only. A total of 901 articles were found not relevant to the review based on title and abstract. Of the remaining 53 records some were identified for possible inclusion and some were unclear due to the absence of an abstract. For articles for possible inclusion, if the title related to aggression management and acute care or if the setting was unknown from title or abstract the article was retrieved. As a result all 53 records were retrieved and the full text of each of the articles was reviewed by two reviewers against the inclusion/exclusion criteria to determine if the article would be included. At this stage of the review a further 41 articles were excluded (Appendix 5).

There were 12 studies deemed relevant for inclusion in the review. The reference lists from each of these articles was also hand-searched for relevant papers. A total of 7 studies were selected from hand-searching. The overall total of studies relevant for this review was 19. Each of these studies was then critically appraised for methodological quality by two independent reviewers. Thirteen studies were found to be of adequate quality with 6 studies excluded. The reasons for the study exclusion are provided in Appendix 5. Figure 1 displays the process used to identify relevant articles for inclusion in the systematic review.

Figure 1: Stages of searching and inclusion/exclusion of references for the review
Figure 1: Stages of searching and inclusion/exclusion of references for the review

Characteristics of included studies

The final number of studies included in the review was 13. A summary of each study is presented in Appendix 6. The included studies in this systematic review were published between 1992 and 2006. No studies published after 2006 met the inclusion criteria. On examining the included studies, it was evident that no two studies were directly comparable and therefore meta-analysis was unable to be utilised. There were 6 randomised controlled trials identified, 4 descriptive studies, 1 prospective cohort, 1 pre-post test design and 1 observational study. The levels of evidence (Appendix 7) of studies presented in this systematic review range from Level 2 to Level 3 evidence based on the Joanna Briggs Institute levels of evidence for effectiveness studies47.

The settings of the studies were similar in that they were all carried out in acute care facilities. Seven studies were set in emergency departments (ED), 1 study involved multiple areas including: ED, geriatric, psychiatric and home healthcare sites, 3 studies utilised staff from various areas within multiple acute care tertiary referral hospitals, 1 was set in medical and surgical areas only and 1 was located in an intensive are unit.

The study participants varied depending on the study design, setting and type of intervention examined. However, all interventions investigated in the studies could be utilised by nurses in the acute care setting to manage patient aggression. Reporting of the results from these studies will be presented according to study intervention. The interventions identified are: staff training programs, chemical restraint, physical restraint, music therapy and the use of multiple interventions. Predominantly, the primary outcome measured in all studies was patient aggression. However, staff confidence, staff attitudes, staff knowledge and skills, frequency of patient aggression and restraint associated complications were additional outcomes considered in some of the studies.

Staff training programs

Three studies investigated the use of staff training programs to reduce the incidence of aggressive and agitated behaviours in patients in the acute care setting. The participants in all three studies consisted of healthcare workers from a variety of acute care settings including geriatric wards and emergency departments. One study also included psychiatric staff, however as the majority of participants were acute care hospital workers it was agreed that this study should be included in the review. Two of the studies were conducted in Australia and one in Sweden.

The paper by Grenyer et al. comprised two small pilot studies. The first study involved experienced aggression trainers from across New South Wales participating in and evaluating a two-day train-the-trainer program. In the second study, experienced healthcare staff (n=48, 33 females, 15 males; mean age = 39.15, SD = 10.74), pre-selected by the pilot site to represent relevant health service occupational backgrounds, completed 4 training modules. Only the results of the second stage of this study will be reported in this systematic review. For stage two, the numbers of participants for each module were: module 1=18, module 2=20, module 3=16 and module 4=10. At the conclusion of program the outcomes assessed were: participants' satisfaction with the program, knowledge acquired, attitudes towards managing aggression and confidence in dealing with aggressive incidents. All participants (n=48) in this second study completed at least 1 module, while 7/48 attended 2 modules, 4/48 attended 3 and 5/48 participants attended all four modules26.

The results of the second pilot study by Grenyer et al. (2004), using Collins Attitudes Toward Aggressive Behaviour Questionnaire, showed significant differences between pre-and post-measurements for four out of eight items indicating an increase in the participant's understanding of the motivations underlying acts of aggression and improved management strategies. Using a 5-point Likert scale to rate responses from 1=strongly disagree to 5=strongly agree, the mean scores and standard deviations in the four areas were: (1) People strike out because they are afraid (Pre 3.49 SD=0.85, Post 3.71 SD=0.75, paired t-test 2.47, p=0.02); (2) People become violent because they feel the only way to defend themselves is to attack first (Pre 3.21 SD=1.01, Post 3.53 SD=0.93, paired t-test 2.46, p=0.02); (3) People threaten staff to get their own way (Pre 3.47 SD=0.96, Post 3.94 SD=0.78, paired t-test 2.95, p=0.01); and (4) I feel confident in my own ability to manage a person's behaviour as it becomes more aggressive (Pre 3.63 SD=0.79, Post 4.03 SD=0.59, paired t-test 3.23, p<0.01)26.

Furthermore, confidence in managing patient aggression was evaluated by Thackrey's previously tested Confidence in Coping with Aggression Instrument48. An analysis of covariance comparing the pre-and post-test scores for those completing more then one module was performed, controlling for the number of modules completed. This analysis found that confidence scores were significantly influenced by the number of modules completed. The more modules completed, the greater the confidence (ANCOVA F=4.03, p=0.04). Overall, the aggression and violence minimisation program evaluated in this study was found to improve staff knowledge, skills, confidence and attitudes towards dealing with violence and aggression in the workplace26.

The next included study by Arnetz and Arnetz investigating staff training programs was set in multiple healthcare settings in Sweden49. The aim of this research was to implement and evaluate a practical intervention program involving regular feedback and group discussions of violent incidents that occurred within the workplace. The program was designed to help staff in healthcare workplaces to manage patient aggression and/or violence towards staff more effectively through de-briefing sessions. The program was part of a controlled prospective study that was conducted over a one-year period that included a baseline questionnaire, the implementation of a violent incident register, the structured intervention program and a follow-up questionnaire. The study population was healthcare workers from 47 healthcare settings (intervention group n=356, control group n=333). The 47 participating work-sites were randomly assigned to either the control or treatment group. An initial background questionnaire was mailed to all healthcare staff at participating worksites. Additionally, a Violent Incidence form was introduced at all study sites and staff were required to report all violent incidents directed towards them over the 1-year study period. The intervention workplaces (n=24) followed a structured program for providing feedback, where circumstances concerning the incidents were discussed on a regular basis with healthcare staff49.

At the conclusion of the 1-year study period, participants were mailed a follow-up questionnaire. There was no significant difference between groups with respect to background information with the exception of years of employment. A greater percentage of staff in the intervention group had worked longer at their respective workplaces (62%) compared with 38% for the control group, (c2= 11.1, p<0.01). There was a significant decrease in the number of overall reported incidents of aggression and/or violence during the course of the study by participants in both the intervention and control groups (62% n=455, c2 =54.3, p<0.0001). Compared with the control group, staff who participated in the program reported: better awareness of risk for violence situations (intervention group = 36%, control group = 29%, c2 =8.6, p <0.05), how potentially violent situations could be avoided (intervention group = 34%, control group = 26%, c2 =5.0, p <0. 05) and how to deal with aggressive patients (intervention group = 33%, control group = 25%, c2 =10.4, p <0.05)49. Logistic regression analysis was used to confirm an increased risk for reported violence in the intervention group post-intervention (odds ratio 1.49; 95% confidence interval 1.07-2.06; P<0.05). Overall the feedback program improved staff knowledge of the risks of violence in the acute healthcare setting49.

The final study on staff training by Deans50 included in this review investigated the effectiveness of a one-day training program for ED nurses in one Australian emergency department. The study focused on increasing nurses' knowledge, skills and attitudes in managing workplace violence and aggression using a non-experimental pre-and post-test design. A total of 40 (66%) nurses working in the emergency department attended the training program. The study evaluated information collected from the nurses via a pre-and post-training questionnaire. Information obtained from the nurses included demographic data, incidence of violence and aggression, confidence in managing violent situations and attitudes about violence and aggression. Thirty of the 40 (75%) nurses who attended the training completed the pre-test questionnaire two months prior to the program and 22 (55%) completed the post-test questionnaire three months following the training50.

Cross tabulations and Chi-square tests were used to analyse the pre-and post-questionnaire data. Following the training workshop, nurses showed a statistically significant improvement in knowledge and understanding for managing aggressive and/or violent situations in the emergency department (c2 =4.18, p=0.04). Nurses reported increased confidence in dealing with aggression from pre-test 86% (26/30) to post-test 95% (21/22). Additionally, the number of aggressive situations encountered following the training program was considerably less post-test (mean 4.0 & SD 3.45) then pre-test (mean 8.39 & SD 11.3). The study results indicated that with training ED nurses can be better prepared to manage violent and aggressive situations and ultimately reduce the incidence of aggression in the workplace50.

The overall results from the three studies investigating the use of staff training programs to prevent and manage patient aggression in acute care settings, has demonstrated that well-designed programs can prepare staff to manage incidents of patient aggression and/or violence. This is achieved by increasing staff knowledge, skills, attitudes and confidence when confronted with this behaviour26, 49, 50.

Chemical restraint

Six studies examined the effectiveness of pharmacological treatments to manage aggressive behaviours in the acute hospital setting. Five of the six studies were randomised controlled trials and one study utilised a prospective cohort design. All of the studies examined or compared different types of drugs for managing aggressive or agitated patients. The decision was made to include these studies in the review based on the fact that despite being ordered by a medical practitioner, all of these drugs may be administered by nurses as "PRN" or "as required" medication.

After reviewing all five RCT's it was revealed that meta-analysis was not appropriate due to the different combinations of drugs used in each of the studies. Five of the studies were set in emergency departments, 1 in Australia and 4 in the United States of America (USA) and 1 in an USA intensive care unit. The length of time the studies were conducted varied from 4 months to 2 years. All study populations were similar as they included patients who were agitated and/or aggressive and all randomised patients to study interventions. Participants were double-blinded where possible however, this did not occur for all the studies. The outcomes measured in these studies include; sedation effects (including time of onset and time to arousal), effects on combativeness, efficacy and effects on symptom reduction and differences between frequency, duration, severity and treatment in young and elderly cohorts in the ICU. Two studies also looked at adverse events as a result of chemical restraint.

The study by Richards et al33 investigated the use of droperidol versus lorazepam for agitated patients in the emergency department. In this RCT, violent and aggressive patients were randomised to receive either lorazepam (<50kg = 2mg IV, >50kg = 4mg IV) or droperidol (<50kg = 2.5 mg IV, >50kg = 5mg IV). A six-point sedation scale was used to evaluate the sedation effects of the administered drug. Sedation scores were recorded at time intervals (0, 5, 10, 15, 30 and 60 minutes). Repeat doses of each drug could be given at 30 minutes if required. The patient's vital signs were taken at 0 and 60 minutes. Toxicology screen, ethanol and creatinine phosphokinase levels were obtained for each patient in the study. A total of 202 patients were evaluated for the study. One hundred patients received lorazepam and 102 were administered droperidol. Both drugs had similar sedation profiles at 5 minutes. Patients receiving droperidol had lower sedation scores when measured at 10 (p=0.89), 15 (p=0.19), 30 (p=0.35) and 60 (p=0.48) minutes compared to those patients who received lorazepam (10min p=0.67, 15min p=0.91, 30min p=0.47, 60min p=0.44). More repeat doses of lorazepam were given (40) then droperidol (8) at 30 minutes. There was a significant reduction in pulse, systolic blood pressure, respiratory rate and temperature over a one-hour period with both study drugs (p<0.05, paired t-test). However, there were no adverse effects from either study drug reported. The study concluded that droperidol produced more rapid and better sedation then lorazepam at the doses used in this study. Lorazepam was more likely to require repeat dosing than droperidol33.

A similar study by Knott, et al.30 used a randomised clinical trial design to compare the use of intravenous droperidol and midazolam for sedation of the acutely agitated patient in the emergency department. The study was double-blinded. All participants were acutely agitated adult patients because of mental illness or intoxication or both. Patients received 5mg intravenously of either midazolam or droperidol (2.5mg if <50kg) every 5 minutes until sedated. Seventy-four patients received midazolam while 79 received droperidol. Survival analysis showed no difference in time to sedation (hazard ratio 0.86; 95% CI 0.61-1.23; p=0.42). Median time to sedation was 6.5 minutes for midazolam (median dose 5mg) and 8 minutes for droperidol (median dose 10mg), (p=0.075; effect size 1.5 minutes; 95% CI - 0-4 minutes). At 5 minutes, 33 of 74 (44.6%) of patients from the midazolam group were adequately sedated compared with 13 of 79 (16.5%) patients from the droperidol group, a difference of 28.1% (95% CI 12.9% to 43.4%; p<0.001). By 10 minutes, 41 of 74 (55.4%) from the midazolam group were sedated compared with 42 of 79 (53.2%) from the patients who received droperidol, a difference of 2.2% (95% CI - 14.9% to 19.3%; p=0.91). Eleven adverse events occurred in the midazolam group and 10 in the droperidol group. The most serious of these were that three patients required active airway management (three with assisted ventilation and one patient was intubated). All of these patients received midazolam30. At the conclusion of the study there was no difference noted between the onset of adequate sedation of agitated patients using either midazolam or droperidol. Although patients sedated with midazolam may have an increased need for active airway management30.

An additional three studies set in emergency departments investigated the use of a combination of midazolam, haloperidol, lorazepam or droperidol for agitated, aggressive or combative patients admitted to emergency departments. All studies used a randomised control design. The first study was double-blinded and set in the emergency departments of five university/general hospitals32. Participants (n=98) were randomly assigned to receive intramuscular injections of lorazepam (2mg), haloperidol (5mg) or both in combination. Patients in each treatment group received 1-6 injections of the same study drug within 12 hours, based on clinical need. Each group was evaluated hourly until 12 hours after the last dose. Efficacy was assessed on the Agitated Behaviour Scale (ABS), a modified Brief Psychiatric Rating Scale (MBPRS), Clinical Global Impressions (CGI) scale and an Alertness scale. Effective symptom reduction was achieved in each treatment group with significant (p<0.01) mean decreases from baseline at every hourly ABS evaluation. Significant (p<0.05) mean differences on the ABS (hour 1) and MBPRS (hours 2 and 3) suggest that tranquillisation was most rapid in patients receiving the combination treatment. Study event incidents (side effects) did not differ significantly between treatment groups. The results indicated that the combination treatment of lorazepam plus haloperidol is the treatment of choice for acute psychotic agitation32.

The next study by Nobay et al.27 also used a prospective, double-blind randomised design to investigate chemical restraint of violently and/or severely agitated patients in an urban community teaching emergency department. This study compared the use of three medications for chemical restraint; midazolam, haloperidol and lorazepam. Participants (n=111) in the study were randomised to receive intramuscular midazolam (5mg), lorazepam (2mg) or haloperidol (5mg). The mean time to sedation was 18.3 minutes for patients receiving midazolam, 28.3 minutes for haloperidol and 32.2 minutes for lorazepam. Midazolam had a significantly shorter time to sedation than lorazepam and haloperidol (p<0.05). The mean difference between midazolam and lorazepam was 13.0 minutes (95% CI = 5.1 to 22.8 minutes) and between midazolam and haloperidol was 9.9 minutes (95% CI = 0.5 to 19.3 minutes). Time to arousal was 81.9 minutes for patients receiving midazolam, 126.5 minutes for haloperidol and 217.2 minutes for lorazepam. Time to arousal for midazolam was significantly shorter than for both haloperidol and lorazepam (p<0.05). The mean difference between times to awakening between midazolam and lorazepam was 135.3 minutes (95% CI = 89 to 182 minutes) and between midazolam and haloperidol was 44.6 minutes. The results of the study indicated that midazolam has a significantly shorter time to onset of sedation and a more rapid time of arousal than lorazepam or haloperidol27.

The final pharmacological study by Thomas et al.29 was set in an ED and investigated droperidol versus haloperidol for agitated and combative emergency department patients. The study was also a prospective, double-blind, randomised control design however it was only carried out on those patients who were already physically restrained and required further chemical restraint. Study participants (n=68) received either haloperidol intramuscularly (IM) (5mg), droperidol IM (5mg), haloperidol IV (5mg) or droperidol IV (5mg). All patients were rated on a five-point combativeness scale at 5, 10, 15, 30 and 60 minute intervals after the study drug was given. Vital signs were also recorded at these times. IM droperidol decreased combativeness significantly more then IM haloperidol at 10 (p =0.006), 15 (p=0.01) and 30 (p=0.04) minutes. There was no significant difference between the two drugs when given by the IV route (p=0.78). The results indicated that when given in equal IM doses, droperidol had a more rapid effect than haloperidol in treating aggressive and agitated patients in the ED29.

The last study included in this review investigating chemical restraint was by Fraser et al.31. This study looked at the frequency, duration, severity and treatment of agitation in patients in the intensive care setting. The study utilised a prospective cohort design and was conducted in a tertiary 10-bed multidisciplinary ICU. Participants were allocated to either the young (<65yrs) or elderly (>65yrs) group based on age and the agitated behaviour of the patients was documented according to causes, severity, frequency, duration and treatment. One hundred and thirty patients were studied for 916 patient-days. Sixty three (48%) were elderly and 67 (52%) were included in the young patient group. Nurses and physicians recorded agitated behaviours in 92 patients (70.8%) during 534 patient-days. Severe or dangerous behaviour was recorded in 60 patients (46.1%) during 273 patient-days31.

The study indicated no age related differences in frequency, severity and duration of agitation. Opiates, benzodiazepines and haloperidol were administered during 72%, 62% and 29% of agitated patient-days respectively. Haloperidol was administered more often to elderly patients (p=0.015), otherwise no between group differences in treatment were noted. Daily dosing requirements were less in the elderly for intermittent intravenous lorazepam, haloperidol and morphine but not for midazolam (p=0.15). When these dosages were corrected for body mass, no statistical differences between young and elderly were found. Adverse events associated with pharmacological management of agitated behaviour was found in 41 patients (44.6%). Adverse events included: excessive sedation (19.2%), haemodynamic instability (12%), aggressive behaviour (7.6%) and respiratory depression (4.4%). Elderly patients experienced an adverse event more frequently (p=0.05) and had a greater incidence of excessive sedation (p=0.17). This study demonstrates that agitation is frequent in ICU patients and that frequency, onset, duration, severity and treatment are similar for elderly and younger patient cohorts31.

The results from the six studies included in this section of the review investigating chemical restraint of aggressive and/or violent patients in the acute care setting reveal that droperidol and midazolam have a more rapid and better sedation effect than lorazepam and haloperidol27, 29, 30, 32, 33. However the use of midazolam may result in greater need for active airway management30. Furthermore, the study by Fraser et al. found no difference in the treatment of agitation between young and elderly patients in the ICU31.

Physical Restraint

Two studies investigated the use of physical restraints in the acute care setting and the effects on patients. A prospective, observational study by Zun focused on consecutive patients who presented to an inner-city ED in one United States of America (USA) hospital and required restraint over a 1-year period35. The ED nurses and physicians were required to complete a restraint checklist that included: the reason for restraint, restraint duration, method and number of restraints, the additional use of chemical restraint and the complications resulting from the use of the restraints. Data from 298 patients was collected over the 1-year period. The mean age of patients was 36.5 years (ranging from 14-89 years). The most frequently restrained age group was 31-40 (29.4%), followed by 21-30 (25.3%), 41-50 (22.3%). Elderly patients (>61 years) were least frequently restrained (5.2%) and 68.2% of restrained patients were male. Psychosis was the most frequent diagnosis of patients who required restraint (33%). One hundred and six patients (40.3%) had more then one reason for needing restraint including: agitation, violence, disruptive behaviour, confusion, dementia and alcohol/drug intoxication.

Patients were restrained for a mean of 4.8 hours ranging from 0.2-25.0 hours. Patients were most frequently restrained on a cart with 2 restraints (59%), in the supine position (86%) and 29.1% had additional chemical restraint added. There were 20 complications recorded over the 1-year study period (7%). The most common complication was patients getting out of the restraints (10) and the remaining complications included: vomiting (3), injuring others (2), spitting (2), injuring self (1), increased agitation (1) and other (1). Complications were not correlated with age, gender, number of restraints, diagnosis or restraint time (p<0.05). Overall, this study demonstrated a low rate of minor complications from the use of physical restraints35.

The second included study was a dissertation that utilised an exploratory design to investigate the factors influencing the use of physical restraints on elderly patients in an acute care setting37. A questionnaire was sent to nurses (n=242) working in medical and surgical wards of three acute care hospitals. There was no statistically significant difference between the wards in terms of age and number of years worked on the ward by nurses in each unit. Nurses were asked to answer questions relating to their knowledge about restraints, their perceptions of their physical and organisational environment and the number of elderly patients restrained on their ward. The results from the study indicated that the majority of nurses in the study believed that patients became more agitated when restraints were used (226, 94%) and most did not think that restraints would calm their elderly patients (234, 98%)37.

Furthermore, the participants did not believe they had administrative or co-worker support to not use restraints (81/242, 35%) or at least were undecided about the level of support (124, 53%); and 187 (78%) thought they would be blamed if an unrestrained elderly patient had a fall. Time constraints was a major factor in the decision to use restraints on elderly patients with 140 (58%, p<0.05) participants agreeing that nurses did not have the time to keep checking patients or that they had inadequate staffing levels (142, 59%, p<0.05). Overall, nurses' knowledge did not influence the use of restraints although there were indications of a lack of knowledge about the harmful effects of restraints.

The results from the study by Zun indicates that the use of physical restraints in the acute care setting results in minor complications for patients35, however nurses in the study by Jacobs had a lack of knowledge regarding the harmful effects of restraints37. Additionally, the nurses in this study did not believe physical restraints were useful in calming their patients and often resulted in increasing agitation and/or aggression.

Music therapy

There was one study that looked at the use of music therapy among nurses in an acute inpatient setting including medical, surgical, cardiology, oncology, ICU and psychiatry51. This descriptive study evaluated the frequency, rationale and perceived effectiveness of the use of music therapy as an independent therapeutic nursing intervention for aggressive and/or agitated patients. A convenience sample of registered nurses (n=321) was selected to participate in the study and received the author-designed questionnaire. The response rate was 42%.

Findings of the study indicated that 85.2% (n=115) of the respondents knew of music therapy, 69.6% (n=94) of them reported using the intervention in their clinical practice. A 3-point Likert scale was used to measure the outcomes of music therapy on aggression and/or agitation in the acute hospital setting. Only 15.6% of general nurses (n=18, mean=2.50, SD=0.51) and 38.5% of psychiatric nurses (n=5, mean=2.00, SD=1.00) reported using music therapy for aggressive patients. Music therapy was most commonly used to enhance sleep and decrease agitation and/or anxiety/stress. The study concluded that the use of music therapy can reduce the incidence of aggressive and/or agitated behaviours however the frequency of use was low51.

Multiple interventions

Only one study evaluated the use of multiple interventions in the management of aggressive and/or violent behaviours from patients in the acute hospital setting in Brisbane, Australia52. This study used a survey tool to elicit information about the aggressor, factors leading to the incident, the nature of the incident, how it was managed and the outcome52. The survey was distributed to all nurses in areas of a metropolitan tertiary hospital, excluding psychiatry over two different periods of time. Sixty-eight survey forms were completed, although a total of 94 incidents were reported during the study period. Nursing staff reported all of the incidents and 74% occurred during the evening and night shift. Sixty-one percent of nurses reporting the incident had previously received aggression management training. Seventeen percent of these nurses reported that they felt the previous education was ineffective in assisting them to manage the situation. However 24 (35%) of the surveys were not completed with regards to patient education52 and therefore this may not be an accurate assessment of the benefits of staff education and training.

The interventions used to manage the behaviour included: verbal negotiation (result not reported), pharmacological intervention (26%), mechanical (physical) restraint (17%) and the use of combined pharmacological and mechanical (physical) restraint (7%). However, a large number of the interventions used to manage the incident were not reported by respondents (50 out of 68). The outcomes reported from the study were: patient injury 21%, staff feeling threatened 85%, staff injury 6%, other patients or relatives feeling threatened 50% and property damage 4%. The overall conclusion of the study was that the majority of aggressive incidents occurred out of hours and that chemical and physical restraint was the most common intervention used to manage the behaviour52.

Discussion

The overall objective of this review was to determine the best available evidence on the prevention and management of aggressive behaviours in acute hospitalised patients. The main interventions that were studied in the acute care setting relating to this topic were: staff training programs, chemical restraint, physical restraint and music therapy. Only one study evaluated the use of multiple interventions to manage acts of aggression and/or violence. There were no studies identified that investigated patient aggression and/or violence prevention strategies in the acute care setting. The discussion of the findings will be organised according to the effectiveness of the interventions on the main outcomes of the systematic review.

Staff training programs

All three studies that investigated staff training programs for increasing healthcare workers' confidence in managing aggressive incidents26, 49, 50 demonstrated some benefits for staff working in the acute care setting. The study by Grenyer et al. [26] suggested that staff training programs may contribute to helping health service industry staff achieve a safer workplace26. The studies by Arnetz & Arnetz49 and Deans50 concluded that a structured program improved healthcare workers' knowledge of the risks of acts of aggression, increased nurses' confidence and skills in managing the behaviour and may have also decreased the amount of aggressive and/or violent incidents encountered by staff.

The findings of these three studies are similar to other reports in the literature suggesting that with some basic training, nurses can be more prepared to manage violent and potentially violent and/or aggressive situations21-23, 25. Generally, this is achieved by raising the awareness of nurses to the nature of the problem of violence and aggression in the acute care setting and developing their knowledge, skills and attitudes in managing the behaviour4. In the study by Arnetz and Arnetz, staff in the intervention group reported improved awareness and management skills when confronted with aggressive and violent patients, while at the same time reporting a greater number of violent incidents than the control group49. The authors suggest that the structured intervention program and group discussions may be responsible for increasing awareness and therefore reporting of violent incidents in the intervention group.

Despite the findings of these three studies, the study by Zernike and Sharpe52, surveying acute care nurses about previous aggressive incidents and how these situations were managed, determined that a number of the nurses in their study felt that some incidents were unavoidable despite previous aggression management training52. Additionally, although the literature highlights the need to educate staff in the prevention and management of aggression21, 22, 53, often little or no training is provided by employers54. Further research has found that training courses vary considerably in length and content and many fail to equip staff with specific knowledge and strategies for managing aggressive and/or violent patients26, 55. There are few reports of intervention studies evaluating staff training programs designed specifically for acute care nurses to manage and reduce the risk of aggressive and/or violent incidents26, 49, 50. Therefore there is considerable scope for further research in this area.

Chemical restraint

The use of specific pharmacological interventions to chemically restrain patients indicates effectiveness in managing aggressiveness and/or agitation in the acute hospital setting. The responsibility for deciding w hich pharmacological intervention is chosen to chemically restrain an aggressive or violent patient will be made by the medical officers on the ward, department or unit where the patient is admitted29. The studies included in this review indicate that droperidol and midazolam were found to be most effective in sedating aggressive and/or violent patients29,30, 33.

The study by Fraser et al.31 evaluating the treatment of agitation in young versus elderly patients admitted to an ICU found no difference between treatment groups. However, the authors concluded that it is difficult to evaluate agitation and/or aggression in ICU patients due to the complexity of their health status and often their inability to communicate31. Furthermore methods for titrating sedation in this patient population can vary considerably56. Another report suggested that age of ICU patients may predict lower sedation requirements57. Fraser et al.31 acknowledged that their study design limited their investigation of these issues.

The use of chemical restraint can have serious adverse effects for the patient and therefore close monitoring is warranted29. The studies by Knott et al. and Battaglia et al. identified several adverse effects from chemical restraint of patients: tremors, ataxia, dizziness, dry mouth and speech disorders and in severe cases an increased need for airway management30, 32. Decreased respiratory depression was commonly associated with the use of intravenous midazolam30. Therefore, it would be inappropriate to use this drug to manage patients in an acute ward setting where close monitoring is limited due to staffing levels and patient acuity. The risks to patients should be considered prior to the initiation of pharmacological therapy for agitation and/or aggression56.

Several limitations were identified in each of the pharmacological studies included in this review. The Knott et al.30 study was susceptible to selection bias as physicians may have failed to enrol patients in the study for whom they had a particular pharmacological treatment preference. Additionally, the timing for administering sedation to the patient was occasionally subjective and may have resulted in slight differences between study participants30. The study by Fraser et al.31 highlighted that as the aetiology of agitation and/or aggression in ICU patients is multifactorial it was unrealistic to solely target agitation and/or aggression. Furthermore the authors suggest that this study may have been underpowered to detect small differences in frequency of agitation and/or aggression between the two cohorts31. None of the studies included used a placebo control group27, 29-33. However, this would have been inappropriate due to the type of participants recruited for the studies.

Physical restraint

The use of physical restraint in one observational study included in this review concluded that the use of restraints resulted in a low rate of minor complications for patients58. This study also found that it was male patients that were most often restrained for violent and disruptive behaviours. Most commonly, physical restraints were used in combination with chemical restraint for an average duration of 5 hours. However these complications were not correlated with age, gender, race, number of restraints, use of chemical restraint, diagnosis or duration of restraint58.

The study by Jacobs37 revealed that nurses felt pressured to use physical restraints when they were unable to observe patients closely due to physical environment constraints, staff shortages or lack of time. Many of the nurses who participated in the study lacked knowledge about the dangers of restraint use37.

Despite the seemingly common use of some form of physical restraint in both the mental health and acute care settings38, 59, 60, there is very little published research on either the efficacy or the subjective effects of restraint on staff or patients60. A systematic review by Nelstrop et al. investigating the safety and effectiveness of restraint and seclusion as interventions for the short-term management of violence in adult psychiatric inpatient settings and emergency departments concluded that there was insufficient evidence to support the safe use of these practices for patients in either of these settings38. The findings of this systematic review concluded that most of the included studies had several limitations, such as small sample sizes, confounders not adequately accounted for, potential selection bias and poorly reported results. None of the studies in the systematic review by Nelstop et al. met the inclusion criteria for this current systematic review38. Further research studies are needed to determine the safety of physical restraints given that nurses are primarily responsible for caring for restrained patients.

Music therapy

A study into the use of music therapy by nurses in the acute care setting indicated that the use of music therapy was relatively low in the acute care setting51. The study found that lack of time and necessary supplies were the two main barriers to the use of music therapy. The authors also suggested that communication to hospital administrators could help develop the support needed to improve the use of music therapy in the clinical setting51.

The use of use music therapy in aged care settings to manage aggressive behaviours is often reported in the literature43, 61, 62. A trial which utilised preferred music at bath time for dementia patients found that this particular intervention was useful in decreasing the number of aggressive and hitting incidents43. Additional interventional studies are needed to identify the benefits of music therapy on aggressive and/or violent patients in the acute care setting.

Multiple interventions

The only included study that evaluated the use of multiple interventions to manage aggressive and/or agitated patients in the acute care setting, found that chemical and physical restraint were the most common combination of interventions used52. Given that, when used independently, specific interventions have positive effects on patient aggression and/or violence it would be reasonable to infer that the use of multiple interventions should result in improved patient outcomes. Further studies are needed to investigate the effectiveness of multiple interventions to prevent and manage aggressive and agitated patients in the acute hospital setting.

Limitations of review

During the process of conducting this systematic review the following limitations were identified. Initial problems with the search strategy became evident when using the subject heading 'healthcare personnel'. The use of this broad heading retrieved an unmanageable number of database hits. Although limiting the search to nurse or nurses may have excluded some studies that referred to healthcare staff, the decision was made by the primary reviewer and librarian to limit search results to nurses. Additionally, nurses were not initially included as study participants however several studies were found that investigated interventions aimed at nursing staff. Staff confidence, knowledge, skills and attitudes were additional outcomes that were revealed as the systematic review progressed.

Implications for practice

Overall there is no strong evidence to support the implementation of interventions to prevent and manage patient aggression and/or violence in the acute care setting. However there is limited evidence to support the use of staff training, chemical and/or physical restraint and music therapy. The implications for clinical practice will be set-out according to study intervention. Ultimately, the implications for practice in the prevention and management of aggressive behaviours in acute hospitalised patients are influenced by the absence of high level research studies in this setting.

Staff training programs

Only three studies were identified that investigated the use of staff training programs to minimise acts of aggression and violence for staff working in acute care setting. None of these studies focused specifically on nurses however nurses were represented in each of the study populations.

All three studies found that training programs were effective in increasing staff confidence when managing aggression and/or violent incidents26, 49, 50, with one of these studies also demonstrating the effectiveness of a training program in helping healthcare staff identify risk factors for acts of aggression49.

Chemical restraint

The use of chemical restraint is useful in managing aggressive and violent patients in the acute care setting27, 29-33. However, intravenous midazolam is not recommended for use in unmonitored acute ward environments due to an increased need for active airway management30. Further research investigating the safety and effectiveness of chemically restraining acute ward patients is required. Pharmacotherapy must be monitored closely for both effectiveness and side effects, with consideration of medication withdrawal when appropriate63.

Physical Restraint

Physical restraints may protect patients and staff from harm from aggressive and/or violent patients and have a low complication rate. However further research is needed for nurses to determine which patients are suitable for physical restraint.

Music therapy

Music therapy can help to reduce the incidence of aggressive and/or agitated behaviours in acute hospitalised patients. To encourage the use of this intervention easy access to supplies and education of the benefits of music therapy for staff need to be implemented51.

Multiple interventions

Further studies are required to determine the benefits of multiple interventions on preventing and managing aggressive behaviours in the acute hospital setting.

It is important to focus more attention on this area of practice in order to change attitudes and responses to aggression and/or violence in the workplace. In addition, valuing staff and ensuring safety would aid in encouraging nurses to stay within the nursing profession.

Recommendations for practice

The following considerations and interventions relating to the prevention and management of aggressive behaviours in acute hospitalised patients have been researched in the clinical area and have implications for clinical practice.

  • Administration of medications helps to reduce the incidence of aggressive and/or violent behaviours in patients in the acute setting and reduces the risk of harm to patients and staff. (Level 2)
  • A training program for staff on managing patient aggression improves self-efficacy and assists staff to manage aggressive and/or violent patients. (Level 3). Further research in the acute care setting is needed.
  • Physical restraints are effective in reducing harm to patients and staff and have minimal complications when used for short periods of time (Level 3). Further research in the acute care setting is needed.
  • Individual interventions such as music therapy have been shown to decrease aggressive and/or agitated behaviours (Level 3). Further research in the acute care setting is needed.

Implications for research

This systematic review has highlighted that the most significant gap in research is the absence of primary studies that investigate the effectiveness of interventions which may prevent and/or reduce aggressive incidents in the acute care setting. More high-quality research in this area would assist in determining whether different interventions would result in improved patient outcomes and less incidents of aggression and/or violence towards acute hospital staff.

Further studies are needed to investigate the use of chemical restraint. More specifically these studies should focus on the types, dosages and administration of medications given to acutely agitated and/or aggressive patients in acute ward settings. Additional research also needs to consider whether improving the written order of these agents will assist doctors and nurses in the selection and administration of these agents.

Research is needed to identify better ways to prepare nurses to manage aggressive and/or violent incidents and to encourage reporting of aggressive and/or violent incidents and near misses. Specifically designed educational programs for acute care nurses need to be developed that aim to increase acute care nurses' confidence, attitudes and knowledge towards aggressive patients. Strategies to decrease staff vulnerability to being assaulted may also reduce the risk of the violence in the workplace. Further research investigating the use of violence risk assessment forms in the acute care settings would help to identify patients most at risk of aggression and/or violence and thereby provide direction for the management of patients at risk. This information would assist in the development of specifically designed education and training programs for acute care nurses to manage patient aggression and violence.

The effects of aggression on hospital staff are wide and varied, including increased absenteeism and sick leave, decreased productivity, reduced job satisfaction and retention64-66. It is often reported that non-somatic effects, psychological and organisational costs are associated with aggression in the workplace15, 55, 64, 65. However there has been little research conducted in these areas. Future areas of research could include investigating the vulnerability factors of both perpetrators and victims of workplace aggression; the aetiology of aggression; and areas, staff and patients most at risk of aggression and/or violence.

Conclusion

This systematic review has highlighted several recommendations for practice in the prevention and management of aggressive behaviours in acute hospitalised patients, including staff training and the administration of medications. However, further higher quality research is needed to assist staff with identifying appropriate interventions to prevent and manage aggressive behaviours in acute hospitalised patients.

Acknowledgements

We would like to extend our thanks to QUT Dr Ruth Elder for her assistance with protocol development, UQ Librarian Kathy Hibberd for her assistance with searching and Annie McArdle for assistance with study retrieval and data management.

References

1. Alexander, C., Occupational violence in an Australian Healthcare setting: Implications for managers. Journal of Healthcare Management, 2004. 49(6): p. 377-390.
2. Winstanley, S. and R. Whittington, Anxiety, burnout and coping styles in general hospital staff exposed to workplace aggression: a cyclical model of burnout and vulnerability to aggression. Work & Stress, 2002. 16(4): p. 302-315.
3. McKenna, B., Risk assessment of violence to others: time for action. Nursing Praxis in New Zealand, 2002. 18(1): p. 36-43.
4. Wells, J. and L. Bowers, How prevalent is violence towards nurses working in general hospitals in the UK? Journal of Advanced Nursing, 2002. 39(3): p. 230-240.
5. Farrell, G., C. Bobrowski, and P. Bobrowski, Scoping workplace aggression in nursing: findings from an Australian study. Journal of Advanced Nursing, 2006. 55(6): p. 778-787.
6. Rippon, T., Aggression and violence in healthcare professions. Journal of Emergency Nursing, 2000. 3(3): p. 214-219.
7. Collins, J., Nurses' attitudes towards aggressive behaviour, following attendance at 'the prevention and management of aggressive behaviours programme'. Journal of Advanced Nursing, 1994. 20: p. 117-131.
8. Duxbury, J., An exploratory account of registered nurses' experience of patient aggression in both mental health and general nursing settings. Journal of Psychiatric and Mental Health Nursing, 1999. 6(2): p. 107-114.
9. Ayranci, U., Violence towards healthcare workers in emergency departments in West Turkey. Journal of Emergency Medicine, 2005. 28(3): p. 361-365.
10. Jackson, D., J. Clare, and J. Mannix, Who would want to be a nurse? Violence in the workplace - a factor in recruitment and retention. Journal of Nursing Management, 2002. 10(1): p. 13-20.
11. Oztunc, G., Examination of incidents of workplace verbal abuse against nurses. Journal of Nursing Care Quality, 2006. 21(4): p. 360-365.
12. Winstanley, S. and R. Whittington, Violence in a general hospital: comparison of assailant and other assault-related factors on accident and emergency and inpatient wards. Acta Psychiatrica Scandinavica, Supplementum, 2002(412): p. 144-7.
13. O'Connell, B., et al., Nurses' perceptions of the nature and frequency of aggression in general ward setting and high dependancy areas. Journal of Clinical Nursing, 2000. 9(4): p. 602-610.
14. Carter, R., High risk of violence against nurses. Nursing Management, 2000. 6(8): p. 5.
15. Lanza, M., R. Zeiss, and J. Rierdan, Non-physical violence: a risk factor for physical violence in health care settings. AAOHN Journal, 2006. 54(9): p. 397-402.
16. Gerberich, S., et al., An epidemiological study of the magnitude and consequences of work related violence: the Minnesota nurses' study. Occupational and Environmental Medicine, 2004. 61(6): p. 495-503.
17. Ryan, J. and E. Poster, Workplace violence: nurses experience of assault by patients. Nursing Times, 1993. 89: p. 38-41.
18. Whittington, R., S. Shuttleworth, and L. Hill, Violence to staff in a general hospital setting. Journal of Advanced Nursing, 1996. 24: p. 326-333.
19. Whittington, R. and T. Mason, A new look at seclusion - stress, coping and the perception of threat. Journal of Forensic Psychiatry, 1995. 6(2): p. 285-304.
20. Mackay, I., B. Paterson, and C. Cassells, Constant or special observations of inpatients presenting a risk of aggression or violence: nurses' perceptions of the rules of engagement. Journal of Psychiatric and Mental Health Nursing, 2005. 12(4): p. 464-471.
21. Beech, B. and P. Leather, Workplace violence in the health care sector: A review of staff training and integration of training evaluation models. Aggression and Violent Behavior, 2006. 11(1): p. 27-43.
22. Nachreiner, N.M., et al., Impact of training on work-related assault. Research in Nursing & Health, 2005. 28(1): p. 67-78.
23. Nield-Anderson, L., et al., Responding to 'difficult' patients: manipulation, sexual provocation, aggression - how can you manage such behaviors? American Journal of Nursing, 1999. 99(12): p. 26-35.
24. Hughes, T.L. and A.M. Medina-Walpole, Implementation of an interdisciplinary behavior management program. Journal of the American Geriatrics Society, 2000. 48(5): p. 581-587.
25. Mion, L.C., et al., Outcomes following physical restraint reduction programs in two acute care hospitals. Joint Commission Journal on Quality Improvement, 2001. 27(11): p. 605-618.
26. Grenyer, B., et al., Safer at work: development and evaluation of an aggression and violence minimization program Australian and New Zealand Journal of Psychiatry, 2004. 38: p. 804-810.
27. Nobay, F., et al., A prospective, double-blind, randomised trial of midazolam versus haloperidol versus lorazepam in the chemical restraint of violent and severely agitated patients. Academic Emergency Medicine, 2004. 11(7): p. 744-749.
28. Currier, G., The controversy over "chemical restraint" in acute care psychiatry. Journal of Psychiatric Practice, 2003. 9(1): p. 59-70.
29. Thomas, H., E. Schwartz, and R. Petrilli, Droperidol versus haloperidol for chemical restraint of agitated and combative patients. Annals of Emergency Medicine, 1992. 21(4): p. 407-413.
30. Knott, J., D. Taylor, and D. Castle, Randomised clinical trial comparing intravenous midazolam and droperidol for the sedation of the acutely agitated patient in the emergency department. Annals of Emergency Medicine, 2006. 47(1): p. 61-67.
31. Fraser, G.L., et al., Frequency, severity, and treatment of agitation in young versus elderly patients in the ICU. Pharmacotherapy, 2000. 20(1): p. 75-82.
32. Battaglia, J., et al., Haloperidol, lorazepam, or both for psychotic agitation? A multicenter, prospective, double-blind, emergency department study. American Journal of Emergency Medicine, 1997. 15(4): p. 335-340.
33. Richards, J., R. Derlet, and D. Duncan, Chemical restraint for the agitated patient in the emergency department: lorazepam versus droperidol. Journal of Emergency Medicine, 1998. 16(4): p. 567-573.
34. Paterson, B. and J. Duxbury, Restraint and the question of validity. Nursing Ethics, 2007. 14(4): p. 535-545.
35. Zun, L.S., A prospective study of the complication rate of use of patient restraint in the emergency department. Journal of Emergency Medicine, 2003. 24(2): p. 119-24.
36. Chan, C.C. and C.H. Chung, A retrospective study of seclusion in an emergency department. Hong Kong Journal of Emergency Medicine, 2005. 12(1): p. 6-13.
37. Jacobs, Y., Factors influencing the use of physical restraints on elderly patients in acute care settings in St. John's, Newfoundland., in School of Nursing. 1995, Memorial University of Newfoundland. p. 200.
38. Nelstrop, L., et al., A systematic review of the safety and effectiveness of restraint and seclusion as interventions for the short-term management of violence in adult psychiatric inpatient settings and emergency departments. Worldviews on Evidence-Based Nursing, 2006. 3(1): p. 8-18.
39. Elbogen, E.B., The process of violence risk assessment: A review of descriptive research. Aggression and Violent Behavior, 2002. 7(6): p. 591-604.
40. Steinert, T., Prediction of inpatient violence. Acta Psychiatrica Scandinavica, 2002. 106(s412): p. 133-141.
41. McNiel, D.E., D.A. Sandberg, and R.L. Binder, The relationship between confidence and accuracy in clinical assessment of psychiatric patients' potential for violence. Law and Human Behavior, 1998. 22(6): p. 655-669.
42. Kling, R., et al., Use of a violence risk assessment tool in an acute care hospital: effectiveness in identifying violent patients. AAOHN Journal, 2006. 54(11): p. 481-7.
43. Clark, M., A. Lipe, and M. Bilbrey, Use of music to decrease aggressive behaviors in people with dementia. Journal of Gerontology Nursing, 1998. 24(7): p. 10-17.
44. Gerdner, L., Effects of individualized versus classical "relaxation" music on the frequency of agitation in elderly persons with Alzheimer's disease and related disorders. International Psychogeriatrics, 2000. 12: p. 49-65.
45. Needham, I., et al., The perception of aggression by nurses: psychometric scale testing and derivation of a short instrument. Journal of Psychiatric and Mental Health Nursing, 2004. 11(1): p. 36-42.
46. Cowin, L., et al., De-escalating aggression and violence in the mental health setting. International Journal of Mental Health Nursing, 2003. 12(1): p. 64-73.
47. Joanna Briggs Institute. JBI Levels of Evidence. Date cited: 8/10/08. Available from: http://www.jbiconnect.org/connect/docs/jbi/cis/connect_gu_manual_view.php?MID=2067. 2008.
48. Thackrey, M., Clinician confidence in coping with patient aggression: assessment and enhancement. Professional Psychology: Research and Practice, 1987. 18(1): p. 57-60.
49. Arnetz, J. and B. Arnetz, Implementation and evaluation of a practical intervention programme for dealing with violence towards healthcare workers. Journal of Advanced Nursing, 2000. 31(3): p. 668-680.
50. Deans, C., The effectiveness of a training program for emergency department nurses in managing violent situations. Australian Journal of Advanced Nursing, 2003. 21(4): p. 17-22.
51. Gagner-Tjellesen, D., E.E. Yurkovich, and M. Gragert, Use of music therapy and other ITNIs in acute care. Journal of Psychosocial Nursing and Mental Health Services, 2001. 39(10): p. 26-37.
52. Zernike, W. and P. Sharpe, Patient aggression in a general hospital setting: do nurses perceive it to be a problem? International Journal of Nursing Practice, 1998. 4(2): p. 126-133.
53. Badger, F. and B. Mullan, Aggressive and violent incidents: perceptions of training and support among staff caring for older people and people with head injury. Journal of Clinical Nursing, 2004. 13(4): p. 526-533.
54. McGowan, S., et al., Staff confidence in dealing with aggressive patients: a benchmarking exercise. Australian and New Zealand Journal of Mental Health Nursing, 1999. 8(3): p. 104-108.
55. Farrell, G. and K. Cubit, Nurses under threat: A comparison of content of 28 aggression management programs. International Journal of Mental Health Nursing, 2005. 14: p. 44-53.
56. Riker, R., J. Picard, and G. Fraser, Prospective evaluation of the sedation-agitation scale in adult ICU patients. Critical Care Medicine, 1999. 27: p. 1325-1329.
57. Lay, T., et al., Analgesics prescribed and administered to intensive care cardiac surgery patients: does patient age make a difference? Progress in Cardiovascular Nursing, 1996. 11: p. 17-24.
58. Zun, L.S. and L. Downey, The use of seclusion in emergency medicine. General Hospital Psychiatry, 2005. 27(5): p. 365-71.
59. Allen, M.H., et al., Treatment of behavioral emergencies: A summary of the expert consensus guidelines. Journal of Psychiatric Practice, 2003. 9(1): p. 16-38.
60. Bonner, G., et al., Trauma for all: a pilot study of the subjective experience of physical restraint for mental health inpatients and staff in the UK. Journal of Psychiatric & Mental Health Nursing, 2002. 9(4): p. 465-473.
61. Cohen-Mansfield, J., Nonpharmacologic interventions for inappropriate behaviors in dementia: A review, summary and critique. Focus, 2004. 2: p. 288-308.
62. Brotons, M. and P. Pickett-Cooper, The effects of music therapy interventions on agitated behaviour of Alzheimer's Disease patients. Journal of Music Therapy, 1996. 33(1): p. 2-18.
63. Herman, M., Neurocognitive functioning and quality of life among dually diagnosed and non-substance abusing schizophrenia inpatients. International Journal of Mental Health Nursing, 2004. 13(4): p. 282-291.
64. Elfering, A., N.K. Semmer, and S. Grebner, Work stress and patient safety: observer-rated work stressors as predictors of characteristics of safety-related events reported by young nurses. Ergonomics, 2006. 49(5-6): p. 457-469.
65. Singh, J., Aggression in U.K. Psychiatric Hospitals. American Journal of Nursing, 2007. 107(11): p. 72.
66. Arnetz, J.E., B.B. Arnetz, and I.L. Petterson, Violence in the nursing profession: Occupational and lifestyle risk factors in Swedish nurses. Work and Stress, 1996. 10(2): p. 119-127.

Appendix 1

Database Search Strategies

Table
Table:
No Caption available.
Table
Table:
No Caption available.
Table
Table:
No Caption available.
Table
Table:
No Caption available.
Table
Table:
No Caption available.
Table
Table:
No Caption available.

Appendix 2

Grey Literature Sites Searched

The New York Academy of Medicine

http://www.nyam.org/library/pages/grey_literature_report

Grey Literature Network Service

http://www.greynet.org/

OpenSIGLE - System for Information on Grey Literature in Europe

http://opensigle.inist.fr/

Bibliotheksservice-Zentrum Baden-Wurttemberg

http://www2.bsz-bw.de/cms/recherche/links/fabio/fabioGRAU.html

BLDSC - British Library Document Supply Centre

http://www.bl.uk/reshelp/atyourdesk/docsupply/collection/rct/

Conrad Dunagan Library: Grey [or Gray] Literature

http://www.utpb.edu/library/greylit.html

EastView Information Services

http://www.eastview.com/russian/books/grey_literature.asp

GLISC, Grey Literature International Steering Committee

http://www.glisc.info

Italian Grey Literature Database

http://www.bice.rm.cnr.it/letteratura_grigia_inglese.htm

LARA - Libre accès aux rapports scientifiques et techniques

http://lara.inist.fr/lara.jsp

Library Association of the City University of New York

http://lacuny.cuny.edu/committees/eis/fall2001/greyinvisible.html

Google Scholar

http://scholar.google.com.au/

Dissertation Abstracts

Appendix 3

Critical Appraisal Tools

Table
Table:
No Caption available.
Table
Table:
No Caption available.
Table
Table:
No Caption available.
Table
Table:
No Caption available.
Table
Table:
No Caption available.

Appendix 4

Data Extraction Tool

Table
Table:
No Caption available.
Table
Table:
No Caption available.

Appendix 5

Retrieved studies excluded as they did not meet the SR inclusion criteria

Allen, M. H., Currier, G. W., Hughes, D. H., Docherty, J. P., Carpenter, D. & Ross, R. (2003) Treatment of behavioral emergencies: a summary of the expert consensus guidelines. Journal of Psychiatric Practice, 9, 16-38.

Reason for exclusion: Wrong setting

Allen, M. H., Currier, G. W., Hughes, D. H., Reyes-Harde, M. & Docherty, J. P. (2001) The Expert Consensus Guideline Series. Treatment of behavioral emergencies. Postgraduate Medicine, 1-88.

Reason for exclusion: Not research

Belgamwar RB, Fenton M. (2005) Olanzapine IM or velotab for acutely disturbed/agitated people with suspected serious mental illnesses. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD003729. DOI: 10.1002/14651858.CD003729.pub2.

Reason for exclusion: SR - References assessed separately

Betemps, E. J., Somoza, E. & Buncher, C. R. (1993) Hospital characteristics, diagnoses, and staff reasons associated with use of seclusion and restraint. Hospital and Community Psychiatry, 44, 367-371.

Reason for exclusion: Wrong setting

Bjorn, P. R. (1991) An approach to the potentially violent patient. Journal of Emergency Nursing, 17, 336-339.

Reason for exclusion: Not research

Bourdinaud, V. & Pochard, F. (2003) Survey of management methods for patients in a state of agitation at admissions and emergency departments in France. Encephale, 29, 89-98.

Reason for exclusion: Study not in English

Bower, F. L., Mccullough, C. S. & Timmons, M. E. (2000) A synthesis of what we know about the use of physical restraints and seclusion with patients in psychiatric and acute care settings. Online Journal of Knowledge Synthesis for Nursing, 7, 23.

Reason for exclusion: Not research

Bower, F. L., Mccullough, C. S. & Timmons, M. E. (2003) A synthesis of what we know about the use of physical restraints and seclusion with patients in psychiatric and acute care settings: 2003 update. Online Journal of Knowledge Synthesis for Nursing, 10, 1-1.

Reason for exclusion: Not research

Brayley, J., Lange, R., Baggoley, C., Bond, M. & Harvey, P. (1994) The violence management team. An approach to aggressive behaviour in a general hospital. Medical Journal of Australia, 161, 254-258.

Reason for exclusion: Not research

Cameron, L. (1998) Verbal abuse: a proactive approach. Nursing Management, 29, 34-36.

Reason for exclusion: Not research

Chan, C. C. & Chung, C. H. (2005) A retrospective study of seclusion in an emergency department. Hong Kong Journal of Emergency Medicine, 12, 6-13.

Reason for exclusion: Retrospective study

Citrome, L., Shope, C. B., Nolan, K. A., Czobor, P. & Volavka, J. (2007) Risperidone alone versus risperidone plus valproate in the treatment of patients with schizophrenia and hostility. International Clinical Psychopharmacology, 22, 356-362.

Reason for exclusion: Wrong setting

Degan, M., Iannotta, M., Genova, V., Opportuni, I., Chiusso, G. & Bonso, O. (2004) The use of physical restraints in an acute care hospital [Italian]. Assistenza Infermieristica e Ricerca, 23, 68-75.

Reason for exclusion: Not in English

Distasio, C. A. (1994) Violence in healthcare: institutional strategies to cope with the phenomenon. Healthcare Supervisor, 12, 1-34.

Reason for exclusion: Not research

Fagan-Pryor, E. C., Femea, P. & Haber, L. C. (1994) Congruence between aggressive behavior and type of intervention as rated by nursing personnel. Issues in Mental Health Nursing, 15, 187-199.

Reason for exclusion: Wrong setting

Freyne, A. & Wrigley, M. (1996) Aggressive incidents towards staff by elderly patients with dementia in a long-stay ward. International Journal of Geriatric Psychiatry, 11, 57-63.

Reason for exclusion: Wrong setting

Friedman, R., Gryfe, C. I., Tal, D. T. & Freedman, M. (1992) The noisy elderly patient: prevalence, assessment, and response to the antidepressant doxepin. Journal of Geriatric Psychiatry And Neurology, 5, 187-191.

Reason for exclusion: Wrong setting

Grossman, S., Labedzki, D., Butcher, R. & Dellea, L. (1996) Definition and management of anxiety, agitation, and confusion in ICUs. Nursing Connections, 9, 49-55.

Reason for exclusion: Qualitative study

Haber, L. C., Fagan-Pryor, E. C. & Allen, M. (1997) Comparison of registered nurses' and nursing assistants' choices of intervention for aggressive behaviors. Issues in Mental Health Nursing, 18, 113-124.

Reason for exclusion: Wrong setting

Huffman, J. C., Stern, T. A., Harley, R. M. & Lundy, N. A. (2003) The use of DBT skills in the treatment of difficult patients in the General Hospital. Psychosomatics, 44, 421-429.

Reason for exclusion: Not research

Hughes, T. L. & Medina-Walpole, A. M. (2000) Implementation of an interdisciplinary behavior management program. Journal of the American Geriatrics Society, 48, 581-587.

Reason for exclusion: Wrong setting

Jones, T. (1999) A descriptive study of nursing interventions for disruptive behaviors in elderly subacute care patients. Baltimore, University of Maryland.

Reason for exclusion: Wrong setting

Jones, J., Borbasi, S., Nankivell, A. & Lockwood, C. (2006) Dementia related aggression in the acute sector: is a Code Black really the answer? Contemporary Nurse: A Journal for the Australian Nursing Profession, 21, 103-115.

Reason for exclusion: Not research

Kling, R., Corbiere, M., Milord, R., Morrison, J. G., Craib, K., Yassi, A., Sidebottom, C., Kidd, C., Long, V. & Saunders, S. (2006) Use of a violence risk assessment tool in an acute care hospital: effectiveness in identifying violent patients. AAOHN Journal, 54, 481-7.

Reason for exclusion: Retrospective and qualitative study

Kurlowicz, L. H. (1990) Violence in the Emergency Department. American Journal of Nursing, 90, 34-39.

Reason for exclusion: Not research

Lanctot, K. L., Best, T. S., Mittmann, N., Liu, B. A., Oh, P. I., Einarson, T. R. & Naranjo, C. A. (1998) Efficacy and safety of neuroleptics in behavioral disorders associated with dementia. Journal of Clinical Psychiatry, 59, 550-561.

Reason for exclusion: SR - studies included are out of the selected timeframe for this review

Lanza, M. L., Anderson, J., Boisvert, C. M., Leblanc, A., Fardy, M. & Steel, B. (2002) Assaultive behavior intervention in the Veterans Administration: psychodynamic group psychotherapy compared to cognitive behavior therapy. Perspectives in Psychiatric Care, 38, 89-97.

Reason for exclusion: Wrong setting

Lewis, C., Sierzega, G. & Haines, D. (2005) The creation of a behavioral health unit as part of the emergency department: One community hospital's two-year experience. Journal of Emergency Nursing, 31, 548-554.

Reason for exclusion: Not research

Mion, L. C., Fogel, J., Sandhu, S., Palmer, R. M., Minnick, A. F., Cranston, T., Bethoux, F., Merkel, C., Berkman, C. S. & Leipzig, R. (2001) Outcomes following physical restraint reduction programs in two acute care hospitals. The Joint Commission Journal on Quality Improvement, 27, 605-618.

Reason for exclusion: Not research

Morrison, E. F., Fox, S., Burger, S., Goodloe, L., Blosser, J. & Gitter, K. (2000) A Nurse-Led, Unit-Based Program To Reduce Restraint Use in Acute Care. Journal of Nursing Care Quality, 14, 72-80.

Reason for exclusion: Not research

Moylan, L. B. (1996) Relationship between the nurse's level of fear, anger and need for control, and the nurse's decision to physically restrain the aggressive patient. Adelphi University.

Reason for exclusion: Wrong setting

Nachreiner, N. M., Gerberich, S. G., Mcgovern, P. M., Church, T. R., Hansen, H. E., Geisser, M. S. & Ryan, A. D. (2005) Impact of training on work-related assault. Research in Nursing and Health, 28, 67-78.

Reason for exclusion: Not research

Nelstrop, L., Chandler-Oatts, J., Bingley, W., Bleetman, T., Corr, F., Cronin-Davis, J., Fraher, D. M., Hardy, P., Jones, S., Gournay, K., Johnston, S., Pereira, S., Pratt, P., Tucker, R. & Tsuchiya, A. (2006) A systematic review of the safety and effectiveness of restraint and seclusion as interventions for the short-term management of violence in adult psychiatric inpatient settings and emergency departments. Worldviews on Evidence-Based Nursing, 3, 8-18.

Reason for exclusion: SR - References assessed separately

O'Connell, B., Young, J., Brooks, J., Hutchings, J. & Lofthouse, J. (2000) Nurses' perceptions of the nature and frequency of aggression in general ward setting and high dependancy areas. Journal of Clinical Nursing, 9, 602-610.

Reason for exclusion: Not research

Rainer, M. K., Masching, A. J., Ertl, M. G., Kraxberger, E. & Haushofer, M. (2001) Effect of risperidone on behavioral and psychological symptoms and cognitive function in dementia. Journal of Clinical Psychiatry, 62, 894-900.

Reason for exclusion: Wrong setting

Riemer, D. & Corwith, C. (2007) Application of core strategies: reducing seclusion & restraint use. On the Edge, 13, 7-10.

Reason for exclusion: Not research

Ryan, C. J. & Bowers, L. (2006) An analysis of nurses' post-incident manual restraint reports. Journal of Psychiatric and Mental Health Nursing, 13, 527-532.

Reason for exclusion: Not research

Schoolfield, M. (1992) Difficult situations in the emergency department: a nursing perspective. Topics in Emergency Medicine, 14, 29-44.

Reason for exclusion: Not research

Sourial, R., Mccusker, J., Cole, M. & Abrahamowicz, M. (2001) Agitation in demented patients in an acute care hospital: prevalence, disruptiveness, and staff burden. International Psychogeriatrics, 13, 183-197.

Reason for exclusion: Study did not investigate interventions

Swett, C. (1994) Inpatient seclusion: Description and causes. Bulletin of the American Academy of Psychiatry and the Law, 22, 421-430.

Reason for exclusion: Wrong setting

To, M. Y. & Chan, S. (2000) Evaluating the effectiveness of progressive muscle relaxation in reducing the aggressive behaviors of mentally handicapped patients. Archives of Psychiatric Nursing, 14, 39-46.

Reason for exclusion: Wrong setting

Retrieved studies excluded after critical appraisal by two reviewers

Carveth, J. A. (1991) An investigation of perceived patient deviance and avoidance/distancing by nurses. Pennsylvania, University of Pennsylvania.

Reason for exclusion: No interventions reported for managing aggressive and/or violent patients.

De Jonge, P., Zomerdijk, M. M., Huyse, F. J., Fink, P., Herzog, T., Lobo, A., Slaets, J. P. J., Arolt, V., Balogh, N., Cardoso, G. & Rigatelli, M. (2001) Mental disturbances and perceived complexity of nursing care in medical inpatients: results from a European study. Journal of Advanced Nursing, 36, 355-363.

Reason for exclusion: Study focus is on all aspects of mental disturbances including depression and alcohol abuse and therefore difficult to apply findings to aggressive patients.

Hodgson, M. J., Reed, R., Craig, T., Murphy, F., Lehmann, L., Belton, L. & Warren, N. (2004) Violence in healthcare facilities: lessons from the Veterans Health Administration. Journal of Occupational and Environmental Medicine / American College of Occupational and Environmental Medicine, 46, 1158-1165.

Reason for exclusion: Wrong setting - Veteran's Health Administration. Study focus is on risk factors and prevalence of violence rather then specific interventions.

Rateau, M. R. (2000) Confusion and aggression in restrained elderly persons undergoing hip repair surgery. Applied Nursing Research, 13, 50-54.

Reason for exclusion: Small sample size and no clear findings for managing patient aggression evident at the conclusion of the study.

West, L. (2003) The effective of an intervention on the risk of eruptive violence in the emergency department. School of Graduate Studies. Connecticut, Southern Connecticut State University.

Reason for exclusion: Wrong setting. Study focus is patients and visitors in the ED waiting room.

Zun LS & Downey L (2005) The use of seclusion in emergency medicine. General Hospital Psychiatry 27, 365-371.

Reason for exclusion: Wrong population. Study utilised a survey design of ED medical directors to investigate the use of seclusion.

Appendix 6

Studies included in the review

Table
Table:
No Caption available.
Table
Table:
No Caption available.
Table
Table:
No Caption available.

Appendix 7

JBI Levels of Evidence of Effectiveness

Table
Table:
No Caption available.
Keywords:

Violence; patient assault; aggression; workplace violence; systematic review

© 2009 by Lippincott Williams & Wilkins, Inc.