Factors That Contribute to Aggressive Behaviors at Inpatient Psychiatric Wards

A systematic review found that aggression in psychiatric wards was due to a combination of patient, ward, and staff factors. These findings were published in PLOS One.

Researchers from Maastricht University in the Netherlands searched publication databases for studies of aggressive behaviors in psychiatric wards. A total of 145 studies were included in this review.

The studies assessed patient factors (n=82), prevalence of aggression (n=71), staff factors (n=55), and ward factors (n=37).

For prevalence of aggression, staff who were 62% women reported a prevalence of any aggression between 65%-99% and for physical aggression between 38%-82%. The weighted prevalence of verbal and physical aggression was 54%. Patients were admitted to a psychiatric ward for a period of 11.6 days to 3 years. Involuntary admission ranged between 21.5%-100%. The proportion of patients who were involved in aggression raged between 7.5%-75.9%, with a weighted prevalence of 23%.

Diagnoses of a psychotic disorders were overrepresented in studies (29%-100%) and were found to have an elevated risk for aggressive behaviors. Aggression was associated with delusional thoughts (odds ratio [OR], 12.39): feeling sad (OR, 11.96), suicidal ideation (OR, 11.59), symptoms of withdrawal (OR, 11.05), thought insertion (OR, 5.06), being spied upon (OR, 4.27), feeling angry (OR, 3.64), feeling restless (OR, 3.41), drug abuse (OR, 2.60), and current alcohol use (OR, 2.19). Violence in a previous admission was predictive of being aggressive (OR, 1.34).

Interactions between staff and patients were an important factor for aggression. Studies found that poor communication or lack of empathy and respect led to aggressive behaviors. Overall, communication contributed to 38% of aggression, interaction 29%, denying the patient something 21%, help with daily activities 8%, and medication administration 7%.

For 37% of acts of aggression, no provocation or trigger was identified. Job strain attributed to aggression (OR, 1.65) and wards that had high rates of conflict had more unqualified staff (P <.001), temporary workers (P <.001), or staff that were more absent (incidence rate ratio [IRR], 1.11).

On days when an aggressive event occurred, the bed occupancy was significantly higher (P <.001) and there were more patients on the ward (P =.05). A 10% excess in patients was associated with the greatest risk for an aggressive event (OR, 2.15). Aggressive behaviors occurred in hallways (14%-67%), the activity room (13%-28%), bedrooms (8.5%-21.9%), the dining room (7%-17%), offices (6.1%-19%), and outside (3.3%).

In general, there were conflicting reports about the role of age and gender among both the patients and staff in the context of aggressive acts.

This review included highly heterogenous studies with differing definitions of aggression and there was an overall lack of controlled studies.

The authors concluded that aggressive events continue to be a major issue among inpatient psychiatric units. A variety of factors contributed to these behaviors. Future studies should focus on prospective naturalistic research.

Reference

Weltens I, Bak M, Verhagen S, et al. Aggression on the psychiatric ward: Prevalence and risk factors. A systematic review of the literature.PLoS One. 2021;16(10):e0258346. doi:10.1371/journal.pone.0258346