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Inpatient aggression in community hospitals

  • Katalin A. Szabo (a1) (a2), Christopher L. White (a1) (a2), Stephen E. Cummings (a3), Raziya S. Wang (a2) (a4) and Cameron D. Quanbeck (a1)...


Physical violence is a frequent occurrence in acute community psychiatry units worldwide. Violent acts by patients cause many direct injuries and significantly degrade quality of care. The most accurate tools for predicting near-term violence on acute units rely on current clinical features rather than demographic risk factors. The efficacy of risk assessment strategies to lower incidence of violence on acute units is unknown. A range of behavioral and psychopharmacologic treatments have been shown to reduce violence among psychiatric inpatients.


Corresponding author

*Address for correspondence: Cameron Quanbeck, MD, Medical Director, Cordilleras Mental Health Center, San Mateo Medical Center, Department of Psychiatry, 200 Edmonds Road, Redwood City, CA 94062, USA. (Email:


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1. Carr, VJ, Lewin, TJ, Sly, KA, et al. Adverse incidents in acute psychiatric inpatient units: rates, correlates and pressures. Aust N Z J Psychiatry 2008; 42(4): 267282.
2. Dack, C, Ross, J, Papadopoulos, C, Stewart, D, Bowers, L. A review and meta-analysis of the patient factors associated with psychiatric in-patient aggression. Acta Psychiatr Scand 2013; 127(4): 255268.
3. Davis, S. Violence by psychiatric inpatients: a review. Hosp Community Psychiatry 1991; 42(6): 585590.
4. Irwin, A. The nurse’s role in the management of aggression. J Psychiatr Ment Health Nurs 2006; 13(3): 309318.
5. Bowers, L, Stewart, D, Papadopoulos, C, et al, Inpatient violence and aggression: a literature review. Report from the Conflict and Containment Reduction Research Programme. London: Section of Mental Health Nursing, Health Service and Population Research, Institute of Psychiatry, Kings College London; 2011.
6. Khoshknab, MF, Tamizi, Z, Ghazanfari, N, Mehrabani, G. Prevalence of workplace violence in psychiatric wards, Tehran, Iran. Pak J Biol Sci 2012; 15(14): 680684.
7. Kay, SR, Wolkenfeld, F, Murrill, LM. Profiles of aggression among psychiatric patients. I. Nature and prevalence. J Nerv Ment Dis 1988; 176(9): 539546.
8. Benjaminsen, SE, Kjaerbo, T. [The staff’s experience of patient violence in a psychiatric department.] Ugeskr Laeger 1997; 159(12): 17681773.
9. Foster, C, Bowers, L, Nijman, H. Aggressive behaviour on acute psychiatric wards: prevalence, severity and management. J Adv Nurs 2007; 58(2): 140149.
10. Flannery, RB Jr, Anderson, E, Marks, L, Uzoma, LL. The Assaulted Staff Action Program (ASAP) and declines in rates of assault: mixed replicated findings. Psychiatr Q 2000; 71(2): 165175.
11. Johnson, ME. Violence on inpatient psychiatric units: state of the science. J Am Psychiatr Nurses Assoc 2004; 10(3): 113121.
12. McNiel, DE, Binder, RL. The relationship between acute psychiatric symptoms, diagnosis, and short-term risk of violence. Hosp. Community Psychiatry 1994; 45(2): 133137.
13. McNiel, DE, Binder, RL, Greenfield, TK. Predictors of violence in civilly committed acute psychiatric patients. Am J Psychiatry 1988; 145(8): 965970.
14. Woods, P, Almvik, R. The Brøset violence checklist (BVC). Acta Psychiatr Scand Suppl 2002; 412: 103105.
15. Woods, P, Ashley, C. Violence and aggression: a literature review. J Psychiatr Ment Health Nurs 2007; 14(7): 652660.
16. Abderhalden, C, Needham, I, Miserez, B, et al. Predicting inpatient violence in acute psychiatric wards using the Broset-Violence-Checklist: a multicentre prospective cohort study. J Psychiatr Ment Health Nurs 2004; 11(4): 422427.
17. Quanbeck, CD, McDermott, BE, Lam, J, Eisenstark, H, Sokolov, G, Scott, CL. Categorization of aggressive acts committed by chronically assaultive state hospital patients. Psychiatr Serv 2007; 58(4): 521528.
18. Powell, G, Caan, W, Crowe, M. What events precede violent incidents in psychiatric hospitals? Br J Psychiatry 1994; 165(1): 107112.
19. Crowner, ML, Peric, G, Stepcic, F, Lee, S. Assailant and victim behaviors immediately preceding inpatient assault. Psychiatr Q 2005; 76(3): 243256.
20. Sheridan, M, Henrion, R, Robinson, L, Baxter, V. Precipitants of violence in a psychiatric inpatient setting. Hosp Community Psychiatry 1990; 41(7): 776780.
21. Ketelsen, R, Zechert, C, Driessen, M, Schulz, M. Characteristics of aggression in a German psychiatric hospital and predictors of patients at risk. J Psychiatr Ment Health Nurs 2007; 14(1): 9299.
22. McNiel, DE, Gregory, AL, Lam, JN, Binder, RL, Sullivan, GR. Utility of decision support tools for assessing acute risk of violence. J Consult Clin Psychol 2003; 71(5): 945953.
23. Harris, GT, Rice, ME. Risk appraisal and management of violent behavior. Psychiatr Serv 1997; 48(9): 11681176.
24. Steinert, T. Prediction of inpatient violence. Acta Psychiatr Scand Suppl 2002; 412: 133141.
25. Cornaggia, CM, Beghi, M, Pavone, F, Barale, F. Aggression in psychiatry wards: a systematic review. Psychiatry Res 2011; 189(1): 1020.
26. Serper, MR, Goldberg, BR, Herman, KG, et al. Predictors of aggression on the psychiatric inpatient service. Compr Psychiatry 2005; 46(2): 121127.
27. Fountoulakis, KN, Leucht, S, Kaprinis, GS. Personality disorders and violence. Curr Opin Psychiatry 2008; 21(1): 8492.
28. McKinlay, WW, Brooks, DN, Bond, MR, Martinage, DP, Marshall, MM. The short-term outcome of severe blunt head injury as reported by relatives of the injured persons. J Neurol Neurosurg Psychiatry 1981; 44(6): 527533.
29. Hare, RD. Psychopathy as a risk factor for violence. Psychiatr Q 1999; 70(3): 181197.
30. Kanerva, A, Lammintakanen, J, Kivinen, T. Patient safety in psychiatric inpatient care: a literature review. J Psychiatr Ment Health Nurs 2013; 20(6): 541548.
31. Pulsford, D, Crumpton, A, Baker, A, Wilkins, T, Wright, K, Duxbury, J. Aggression in a high secure hospital: staff and patient attitudes. J Psychiatr Ment Health Nurs 2013; 20(4): 296304.
32. Duxbury, J, Whittington, R. Causes and management of patient aggression and violence: staff and patient perspectives. J Adv Nurs 2005; 50(5): 469478.
33. Lavender MST. Putting aggression into context: an investigation into contextual factors influencing the rate of aggressive incidents in a psychiatric hospital. Journal of Mental Health 1999; 8(2): 159170.
34. Flannery, RB Jr, Corrigan, M, Hanson, MA, Walker, AP. Past violence, substance use, and precipitants to psychiatric patient assaults: eleven-year analysis of the Assaulted Staff Action Program (ASAP). Int J Emerg Ment Health 2006; 8(3): 157163.
35. Cooper, AJ, Mendonca, JD. A prospective study of patient assaults on nurses in a provincial psychiatric hospital in Canada. Acta Psychiatr Scand 1991; 84(2): 163166.
36. Rasmussen, K, Levander, S. Individual rather than situational characteristics predict violence in a maximum security hospital. Journal of Interpersonal Violence 1996; 11(3): 376390.
37. Longo, DA, Bisconer, SW. Treatment of aggression for an adult diagnosed with schizophrenia at a public psychiatric hospital. Professional Psychology: Research and Practice 2003; 34(2): 177179.
38. Bowers, L, Allan, T, Simpson, A, Jones, J, Van Der Merwe, M, Jeffery, D. Identifying key factors associated with aggression on acute inpatient psychiatric wards. Issues Ment Health Nurs 2009; 30(4): 260271.
39. Nijman, HL, Rector, G. Crowding and aggression on inpatient psychiatric wards. Psychiatr Serv 1999; 50(6): 830831.
40. Ng, B, Kumar, S, Ranclaud, M, Robinson, E. Ward crowding and incidents of violence on an acute psychiatric inpatient unit. Psychiatr Serv 2001; 52(4): 521525.
41. Virtanen, M, Vahtera, J, Batty, GD, et al. Overcrowding in psychiatric wards and physical assaults on staff: data-linked longitudinal study. Br J Psychiatry 2011; 198(2): 149155.
42. Barlow, K, Grenyer, B, Ilkiw-Lavalle, O. Prevalence and precipitants of aggression in psychiatric inpatient units. Aust N Z J Psychiatry 2000; 34(6): 967974.
43. Hamrin, V, Iennaco, J, Olsen, D. A review of ecological factors affecting inpatient psychiatric unit violence: implications for relational and unit cultural improvements. Issues Ment Health Nurs 2009; 30(4): 214226.
44. Bader, S, Evans, SE, Welsh, E. Aggression among psychiatric inpatients: the relationship between time, place, victims, and severity ratings. J Am Psychiatr Nurses Assoc 2014; 20(3): 179186.
45. Mossman, D. Assessing predictions of violence: being accurate about accuracy. J Consult Clin Psychol 1994; 62(4): 783792.
46. Douglas, KS, Ogloff, JR, Nicholls, TL, Grant, I. Assessing risk for violence among psychiatric patients: the HCR-20 violence risk assessment scheme and the Psychopathy Checklist: Screening Version. J Consult Clin Psychol 1999; 67(6): 917930.
47. Wong, SCP, Gordon, A. The validity and reliability of the Violence Risk Scale: a treatment-friendly violence risk assessment tool. Psychology, Public Policy, and Law 2006; 12(3): 279309.
48. Singh, JP, Fazel, S. Forensic risk assessment: a metareview. Criminal Justice and Behavior 2010; 37(9): 965988.
49. Steadman, HJ, Silver, E, Monahan, J, et al. A classification tree approach to the development of actuarial violence risk assessment tools. Law Hum Behav 2000; 24(1): 83100.
50. Allen, J. Assessing and managing risk of violence in the mentally disordered. J Psychiatr Ment Health Nurs 1997; 4(5): 369378.
51. Palmstierna, T, Wistedt, B. Risk factors for aggressive behaviour are of limited value in predicting the violent behaviour of acute involuntarily admitted patients. Acta Psychiatr Scand 1990; 81(2): 152155.
52. Almvik, R, Woods, P, Rasmussen, K. The Brøset Violence Checklist: sensitivity, specificity, and interrater reliability. Journal of Interpersonal Violence 2000; 15(12): 12841296.
53. Elbogen, EB, Tomkins, AJ, Pothuloori, AP, Scalora, MJ. Documentation of violence risk information in psychiatric hospital patient charts: an empirical examination. J Am Acad Psychiatry Law 2003; 31(1): 5864.
54. Gardner, W, Lidz, CW, Mulvey, EP, Shaw, EC. Clinical versus actuarial predictions of violence of patients with mental illnesses. J Consult Clin Psychol 1996; 64(3): 602609.
55. Abderhalden, C, Needham, I, Dassen, T, Halfens, R, Haug, HJ, Fischer, JE. Structured risk assessment and violence in acute psychiatric wards: randomised controlled trial. Br J Psychiatry 2008; 193(1): 4450.
56. Ogloff, JRP, Daffern, M. The dynamic appraisal of situational aggression: an instrument to assess risk for imminent aggression in psychiatric inpatients. Behav Sci Law 2006; 24(6): 799813.
57. Almvik, R, Woods, P. Predicting inpatient violence using the Brøset Violence Checklist (BVC). Int J Psychiatr Nurs Res 1999; 4(3): 498505.
58. Chu, CM, Daffern, M, Ogloff, JRP. Predicting aggression in acute inpatient psychiatric setting using BVC, DASA, and HCR-20 Clinical scale. Journal of Forensic Psychiatry & Psychology 2013; 24(2): 269285.
59. Beck, JC, White, KA, Gage, B. Emergency psychiatric assessment of violence. Am J Psychiatry 1991; 148(11): 15621565.
60. Allen, M, Forster, P, Zealberg, J, et al, Report and recommendations regarding psychiatric emergency and crisis services: a review and model program descriptions. American Psychiatric Association Task Force. 2002. Accessed September 1, 2014.
61. Huf, G, Coutinho, ESF, Adams, CE. Rapid tranquillisation in psychiatric emergency settings in Brazil: pragmatic randomised controlled trial of intramuscular haloperidol versus intramuscular haloperidol plus promethazine. BMJ 2007; 335: 869.
62. Raveendran, NS, Tharyan, P, Alexander, J, Adams, CE. Rapid tranquillisation in psychiatric emergency setting in India: pragmatic randomised controlled trial of intramuscular olanzapine versus intramuscular haloperidol plus promethazine. BMJ 2007; 335(7625): 865869.
63. Powney, MJ, Adams, CE, Jones, H. Haloperidol for psychosis-induced aggression or agitation (rapid tranquillisation). Cochrane Database Syst Rev 2012; 11: CD009377.
64. Baldaçara, L, Sanches, M, Cordeiro, DC, Jackoswski, AP. Rapid tranquilization for agitated patients in emergency psychiatric rooms: a randomized trial of olanzapine, ziprasidone, haloperidol plus promethazine, haloperidol plus midazolam and haloperidol alone. Rev Bras Psiquiatr 2011; 33(1): 3039.
65. Bosanac, P, Hollander, Y, Castle, D. The comparative efficacy of intramuscular antipsychotics for the management of acute agitation. Australas Psychiatry 2013; 21(6): 554562.
66. Kinon, BJ, Stauffer, VL, Kollack-Walker, S, Chen, L, Sniadecki, J. Olanzapine versus aripiprazole for the treatment of agitation in acutely ill patients with schizophrenia. J Clin Psychopharmacol 2008; 28(6): 601607.
67. Gillies, D, Sampson, S, Beck, A, Rathbone, J. Benzodiazepines for psychosis-induced aggression or agitation. Cochrane Database Syst Rev 2013; 4: CD003079.
68. Wallace, PS, Taylor, SP. Reduction of appeasement-related affect as a concomitant of diazepam-induced aggression: Evidence for a link between aggression and the expression of self-conscious emotions. Aggress Behav 2009; 35(2): 203212.
69. Wilson, MP, MacDonald, K, Vilke, GM, Feifel, D. Potential complications of combining intramuscular olanzapine with benzodiazepines in emergency department patients. J Emerg Med 2012; 43(5): 889896.
70. Keating, GM. Loxapine inhalation powder: a review of its use in the acute treatment of agitation in patients with bipolar disorder or schizophrenia. CNS Drugs 2013; 27(6): 479489.
71. Citrome, L. Aerosolised antipsychotic assuages agitation: inhaled loxapine for agitation associated with schizophrenia or bipolar disorder. Int J Clin Pract 2011; 65(3): 330340.
72. Currier, G, Walsh, P. Safety and efficacy review of inhaled loxapine for treatment of agitation. Clin Schizophr Relat Psychoses 2013; 7(1): 2532.
73. Sheehan, B, Burton, E, Wood, S, Stride, C, Henderson, E, Wearn, E. Evaluating the built environment in inpatient psychiatric wards. Psychiatr Serv 2013; 64(8): 789795.
74. Southard, K, Jarrell, A, Shattell, MM, McCoy, TP, Bartlett, R, Judge, CA. Enclosed versus open nursing stations in adult acute care psychiatric settings: does the design affect the therapeutic milieu? J Psychosoc Nurs Ment Health Serv 2012; 50(5): 2834.
75. Ulrich, RS, Zimring, C, Zhu, X, et al. A review of the research literature on evidence-based healthcare design. HERD 2008; 1(3): 61125.
76. Ulrich, RS, Berry, LL, Quan, X, Parish, JT. A conceptual framework for the domain of evidence-based design. HERD 2011; 4(1): 95114.
77. Douglas, CH, Douglas, MR. Patient-centred improvements in health-care built environments: perspectives and design indicators. Health Expect 2005; 8(3): 264276.



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