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Aggression Among Psychiatric Inpatients: The Relationship Between Time, Place, Victims, and Severity Ratings Shannon Bader, Sean E. Evans and Elena Welsh Journal of the American Psychiatric Nurses Association 2014 20: 179 DOI: 10.1177/1078390314537377 The online version of this article can be found at: http://jap.sagepub.com/content/20/3/179

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JAPXXX10.1177/1078390314537377Journal of the American Psychiatric Nurses AssociationBader et al.

Original Article

Aggression Among Psychiatric Inpatients: The Relationship Between Time, Place, Victims, and Severity Ratings

Journal of the American Psychiatric Nurses Association 2014, Vol. 20(3) 179­–186 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1078390314537377 jap.sagepub.com

Shannon Bader1, Sean E. Evans2, and Elena Welsh3

Abstract BACKGROUND: The rate of aggressive acts perpetrated by psychiatric inpatients remains a pressing issue. To date, few studies have distinguished between incident severities. OBJECTIVE: The aims of the current study were to identify rates of inpatient aggression in an inpatient forensic psychiatric facility and describe the severity of the aggression reported for aggressive incidents. DESIGN: All documented acts of aggression at a 1,500-bed forensic hospital between 2009 and 2013 provided data about the time, location, and victims of aggressive acts. In total, 52,109 unique incidents were analyzed. RESULTS: The findings showed an increase in violence rates during meal, medication, and shift change times. Patients (n = 3,436, 62%) were victimized more often than staff members (n = 2,103, 38%). Fall and winter months showed more acts of aggression than summer and spring, but there were no mean differences between severity ratings by season. The results showed that the swing shift saw more severe aggressive incidents than the morning or overnight shifts, p = .001, and significantly more serious incidents occurred when there were staff members working over time, p = .050. CONCLUSIONS: The current study reports some key findings about aggression rates with a very large sample and presents some valuable data regarding the severity of aggressive acts. Keywords state hospitals, violence/aggression, forensic psychiatry/legal issues

Introduction For decades, violence and aggressive behavior has been identified as a pressing issue facing institutional settings such as psychiatric facilities (Needham et al., 2004). Likely due to acute illness severity and increased frequency of contact, assault rates against staff and other patients appear to be much higher in inpatient versus community mental health settings (Flannery, Staffieri, Hildum, & Walker, 2011). Past research has indicated that approximately 25% to 35% of inpatients exhibit violent behavior while in the hospital (Arango, Calcedo Barba, GonzalezSalvador, & Calcedo Ordonez, 1999; Daffern, Mayer, & Martin, 2003). Because admission to forensic psychiatric facilities typically results from dangerousness or past illegal acts, the likelihood of inpatient violence within these specialized types of facilities is especially notable (Quanbeck, 2006). The consequences of violence in these settings are far reaching and affect both staff and patients. A Bureau of Labor Statistics report indicates that assaults by patients accounted for 7% of workplace injuries to nurses and psychiatric aides over a 10-year period and that

nurses experienced a higher proportion of assaults than any other occupational group (U.S. Department of Labor, Bureau of Labor Statistics, 2006). Indeed, Daffern et al. (2003) found that within their Australian forensic hospital, nursing staff were more likely to be victimized than other staff groups. Although previous research has reported rates of violence and injuries, less focus has been paid to the severity of incidents. Indeed, existing findings have suggested that approximately one in four psychiatric nurses in a publicly funded facility suffers a disabling injury from a patient assault each year (Love & Hunter, 1996). The severe assaults resulting in career-ending injuries cause 1

Shannon Bader, PhD, Patton State Hospital, Patton, CA, USA Sean E. Evans, PhD, Patton State Hospital, Patton, CA; La Sierra University, Riverside, CA, USA 3 Elena Welsh, PhD, Patton State Hospital, Patton, CA, USA 2

Corresponding Author: Shannon Bader, California Department of State Hospitals, Patton State Hospital, 3102 E. Highland Ave., Patton, CA 92369, USA. Email: [email protected]

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the most financial cost to facilities but also may have the greatest effect on staff morale, work satisfaction, and treatment milieu (Hunter & Carmel, 1992). Consequently, the aims of the current study are (a) to identify rates of inpatient aggression in an inpatient forensic psychiatric facility and (b) to describe the severity of the aggression reported for aggressive incidents.

safety increased with more male staff present, Daffern et al. (2006) found that there was no significant relationship between the proportion of male staff on a shift and violence rates. Some research has indicated that the proportion of male versus female staff victims differs depending on the context of the violent incident. For instance, in research examining assault rates in the American hospitals, female staff were more likely the victim of unprovoked violence (75%), whereas men and women were equally likely to be victims of assault during seclusion procedures (Flannery et al., 1994). Not surprisingly, research has confirmed expectations that more experience and formal training decreases staff risk for assault (Flannery et al., 1994; Flannery et al., 2011; Flannery, White, Flannery, & Walker, 2007;). Relatedly, younger staff members have also been identified as being at increased risk for assault (Flannery et al., 2011). Little consistency is found among previous studies comparing rates of aggression by month (Daffern et al., 2003). For example, Daffern et al. (2003) found that the highest incident rates at an Australian forensic hospital occurred in September (33 incidents), and the least number of incidents occurred in October (10 incidents). Other researchers who examined temporal patterns in incident rates in seven state hospitals in the United States found that August was the highest risk month (10% of incidents), whereas February had the lowest rates (6%; Flannery, Farley, et al., 2007). In another study, the same researchers found that, in general, warmer months tended to correlate with higher incident rates (Flannery et al., 1994). Researchers at a Finnish forensic hospital found that there was significantly more violence during months with more daylight; spring and summer had higher rates than fall and winter (WeizmannHenelius & Suutala, 2000). With regard to time of day, Daffern et al. (2003) found that incident rates were evenly distributed between 9 a.m. and 11 p.m., with no incidents recorded from midnight to 5 a.m. Flannery, White, et al. (2007) found higher incident rates in state hospitals during the first shift (8 a.m. to 11 a.m.; 56% of incidents). In one of the few existing studies to explore severity, Cheung et al. (1996) utilized the Staff Observation of Aggression Scale in order to classify the severity of each aggressive incident and found that the highest rate of violent incidents occurred in the morning but that the most severe incidents in their facility occurred in the afternoon. However, scheduled daily activities may have more relationship to aggression rates than the time on the clock. For example, researchers have found higher inpatient violence rates during shift change and mealtime transitions (Balderston, Negley, Kelly, & Lion, 1990; Weizmann-Henelius & Suutala, 2000).

Previous Research Many previous researchers have asked which people are most often victimized in acts of institutional aggression. To date, the findings remain quite mixed. In a study conducted at the largest psychiatric hospital in Victoria, Australia, 61.4% of violent incidents were directed at staff members versus 32.4% that were directed at other patients (Cheung, Schweitzer, & Tuckwell, 1996). This finding was nearly an exact inverse to a California study showing 60% of victims were patients and 40% were staff members (Quanbeck et al., 2007). However, a later study from the Australian hospital showed variation in rates of victimization between housing units (Daffern et al., 2003). Specifically, the researchers found that on one unit, staff and patients were equally the victims of physical aggression, with 17 incidents each, whereas on another unit in the same hospital, more incidents against other patients (26 incidents) were recorded than against staff members (4 incidents). Yet another study conducted in the same hospital at a different time point found that staff were far more likely to be the victims of aggression (222 incidents, 70.3%) than patients (61 incidents, 19.3%; Daffern, Mayer, & Martin, 2006). Other researchers examining aggression in a Finnish forensic hospital have found that violence aimed at staff and patients was relatively equally distributed (Weizmann-Henelius & Suutala, 2000). Importantly, it is plausible that incidents directed at staff are more likely to be formally reported than those directed at other patients. For instance, in the Australian study, only 173 formal incident reports were filed out of 806 incidents recorded as part of the research program (Cheung et al., 1996). Daffern et al. (2003) found that male staff were more likely to be victims than female staff (84 vs. 37 incidents), although female staff were exclusively the victims of sexual aggression. The study also indicated that aggressive incidents tended to involve victims and perpetrators of the same sex. Because male patients were responsible for 82% of the recorded incidents, this may have contributed to higher rates of male victims. In contrast, research conducted in select state hospital systems in the United States has found that female staff are more likely to be assault victims (Flannery, Farley, Rego, & Walker, 2007; Flannery, Hanson, & Penk, 1994). Despite staff perceptions that

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Method

information is entered into a hospital-wide electronic database. Hospital staff members are provided training on the Incident Management System documentation at new employee orientation and receive additional training on a yearly basis. Hospital policy dictates that Incident Management System paperwork be completed after any act of aggression and the level of supervision provided at a forensic facility suggests that most aggression would be witnessed and documented. The two first authors, psychologists who have ethics and confidentiality training required for licensure as well as yearly training in HIPPA regulations, transferred all incidents classified as aggression toward staff members or aggression toward other patients from the Incident Management System’s electronic database into an SPSS statistics program. No estimates of interrater reliability are available because the transfer was done entirely electronically and involved populating cells in the statistics program with identical data cells in the Incident Management System’s existing database. Once the electronic data were transferred to the statistics program, all patient identifying information and staff member names were removed before any analyses commenced. The Incident Management System defines an aggressive act as “hitting, pushing, kicking or similar acts directed against another individual to cause potential or actual injury.” Incidents involving verbal threats or property damage alone are not classified as aggressive and were not included in this study.

The current study was conducted at a 1,500-bed, maximum-security forensic hospital near Los Angeles, California. The patients admitted to the hospital are diverse in terms of race (32% Caucasian, 20.3% African American, 14.2% Hispanic, 2.8% Asian, 5.4% other) and have a wide degree of psychiatric diagnosis including schizophrenia, bipolar disorder, schizoaffective disorder, major depressive disorder, various substance abuse disorders, and personality disorders. Like other forensic hospitals, most patients have been committed to the hospital after being found incompetent to stand trial or adjudicated not guilty by reason of insanity. Additionally, the facility has patients committed under California’s mentally disordered offender statute and female patients transferred from correctional institutions because of severe psychiatric symptoms. The hospital’s acute units typically house new patients for the first 90 days of admission. Some patients, especially those who quickly became competent to stand trial, will be discharged directly from an acute unit. Long-term units tend to be focus more on chronic psychiatric symptoms and preparation for discharge to community programs. Approval for this study was obtained from the Institutional Review Board of La Sierra University and the California Committee for the Protection of Human Subjects. Because of the seriousness of inpatient aggression, the California state hospital system developed an Incident Management System in 1996 to identify, classify, and document aggressive incidents. After an aggressive incident occurs, a staff member completes the official documentation that describes the event, identifies the persons involved, provides the time and location of the aggression, and includes information about staffing levels and injury severity. Severity ratings can range from 1 to 4. A rating of 1 indicates no injury, and a rating of 2 indicates the need for minor first aid treatment, usually provided by the unit nursing staff. A severity rating of 3 requires the treatment of a doctor, either on the housing unit or in a community emergency room. A severity rating of 3 typically includes sutures, broken bones, and the need for prescription pain medications. A rating of 4 for severity requires admission to a community hospital, regardless of length of stay. For a rating of 4, the patient or staff member has needed more treatment than can be provided in an emergency room. Importantly, these severity ratings are based on the amount of physical injury sustained by persons involved, not the intensity or amount of fear that can also result from an aggressive incident. Every staff member at the facility receives extensive training in how to complete the form in a standardized manner. Once completed, the Incident Management System paper form is filed in the patient’s chart and the

Results All documented acts of aggression between August 2009 and March 2013 were included in this study, resulting in 5,219 unique aggressive incidents. Acute units recorded 2,748 (52.7%) incidents, and long-term units recorded 2,471 (47.3%) incidents. There was no significant relationship between unit type and injury severity. Two or more aggressors were identified in 1,435 incidents, leading to a total of 6,656 patients labeled as an aggressor. The majority of aggressors were male (n = 4,498, 62.6%), and aggressors ranged in age from 17 to 90 years (M = 39.08, SD = 12.07). The largest proportion of the aggressors (n = 2,796, 42%) were committed to the hospital as Incompetent to Stand Trial, followed by Mentally Disordered Offenders (n = 1,661, 24.9%) and Not Guilty by Reason of Insanity acquittees (n = 1,504, 22.6%). The average length of stay for the patients identified as aggressors was 3.2 years (SD = 4.94 years), with some leaving the hospital within 1 month of admission while others have stayed over 35 years and continue to reside at the hospital. Overwhelmingly, the patients identified as aggressors had a primary diagnosis of schizophrenia or schizoaffective disorder (n = 4,510, 67.76%).

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Twenty-six percent (n = 1,778) had a diagnosis of antisocial personality disorder, and nearly 6% (n = 391) had a diagnosis of borderline personality disorder. No information on patient ethnicity is collected in the Information Management System and therefore is not reported here.

Victim Results Although some aggressive acts resulted in multiple victims, sometimes both staff and patient, the majority of victims were other patients (n = 3,436, 62%). From this sample, 38% (n = 2,103) of victims were staff members. This ratio was the same for acute and long-term units. The gender, years of experience, and discipline of the victimized staff member are not recorded in the Incident Management System. The staff victims received mostly minor physical injuries; 85.7% (n = 1,803) had no reported injury, 12.4% (n = 260) received minor first aid, 1.7% (n = 36) needed treatment from a doctor, and 0.2% (n = 4) required overnight care in a hospital. The majority of patient victims were male (n = 2,362, 68.7%), and victims ranged in age from 17 to 89 years (M = 42.23, SD = 12.28). The largest proportion of the victims (n = 1,441, 41.9%) were committed to the hospital as Incompetent to Stand Trial, followed by Not Guilty by Reason of Insanity acquittees (n = 881, 25.6%) and Mentally Disordered Offenders (n = 810, 23.6%). The average length of stay for the victimized patients was 3.5 years (SD = 5.3 years), with a range from 1 month to 37 years. Overwhelmingly, the patients identified as victims had a primary diagnosis of schizophrenia or schizoaffective disorder (n = 2,374, 69.1%). Nineteen percent (n = 666) had a diagnosis of antisocial personality disorder, and nearly 5% (n = 159) had a diagnosis of borderline personality disorder. The patient victims received mostly minor physical injuries; 58.1% (n = 1,995) had no reported injury, 37.3% (n = 1,283) received minor first aid, 4.4% (n = 150) needed treatment from a doctor, and 0.2% (n = 8) required overnight care in a hospital. Aggressors’ age showed no correlation to the severity of victim injury. Means testing also showed no difference between the mean ages of aggressors perpetrating various levels of physical injury severity. Aggressors’ length of stay at the hospital also showed no correlation to the severity of victim injury. Similarly, analysis of variance showed no difference between aggressors’ mean length of stay and the levels of physical severity. Because of the small number of incidents requiring overnight care in a hospital (classified as Level 4 severity), the levels of severity were condensed into two categories, low injury severity, which included Levels 1 and 2, and high injury severity, which included Levels 3 and 4, for some analyses. For example, a cross-tabulation of acute or long-term units versus low or high injury severity showed

Figure 1.  Number of incidents by hour.

no significant relationship. A cross-tabulation of perpetrator gender showed that male aggressors were responsible for 83.7% (n = 128) of the high medical need injuries versus 16.3% (n = 25) perpetrated by females while aggressive women perpetrated 32.8% (n = 2,133) of the low medical need injuries and men perpetrated 67.2% (n = 4,366). Although this was a significant relationship, χ2(1) = 18.53, p < .001, the effect size was sufficiently low, Φ = −0.053, to suggest that it is not a meaningful difference. A cross-tabulation of low or high injury severity and patient or staff victims showed no significant relationship.

Temporal and Location Results An examination of time of day showed that day shift and swing shift had similar numbers of aggressive incidents. Aggressive incidents during the swing shift accounted for 50.6% (n = 2,641) of the aggressive acts, whereas incidents during the day shift accounted for 43.4% (n = 2,266) of the documented acts. The overnight shift saw 6% (n = 314) of the aggressive incidents during this study period. A breakdown of the daily hours showed that the most aggressive incidents occurred between 4 p.m. and 7 p.m. (354, 427, 452, and 374 incidents, respectively). The next highest hour was 8 a.m., with 348 incidents (6.7%). However, using outlier analysis, no hour was statistically different from the others. As seen in Figure 1, the three spikes consistent with typically busy times on unit (meals, medications, and staff changes) are visible. Despite the similar number of events taking place during the day and swing shifts, there were significant mean differences in the severity ratings by shift, F(2, 5,216) = 6.643, MSE = 1.338, p = .001. Pairwise comparisons using the Games-Howell test (the assumption of homogeneity of variances was violated, Levene test < .05) revealed that

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Bader et al. significantly more severe events took place during the swing shift than the morning or overnight shifts. Out of all 5,219 incidents, 43.3% (n = 2,260) occurred when all regularly scheduled staff members were on duty and 57% (n = 2,959) occurred with one or more staff working an overtime shift. The same pattern was seen with severe incidents; out of the 153 severe incidents, 37.9% (n = 58) occurred when all regularly scheduled staff members were on duty and 62.1% (n = 95) occurred when there were one of more overtime staff present. There was a significant difference in the mean severity ratings when overtime staff were present (M = 1.21) or not (M = 1.18), F(1, 5,217) = 3.83, MSE = 0.77, p = .050; however, the effect size was once again very low, η2 = 0.001. As shown in Table 1, the incidence of aggression ranged from 587 on Saturdays to 822 on Thursdays. Outlier analysis showed that no day was statistically different from another. There was a trend level effect when comparing the severity of aggression on weekends versus weekdays, F(2, 5,217) = 3.57, MSE = 0.721, p = .059, with the weekdays having a lower mean average of severity ratings (x = 1.19) than the weekends (x = 1.22). Despite this trend level relationship, the effect size was sufficiently low, η2 = 0.001, to suggest that it is not a meaningful difference. Table 2 highlights that the numbers of incidents range from 339 in July to 509 in January, but outlier analysis showed that no month was statistically different from another. The average severity ratings did not show any statistically significant mean differences. Months were then collapsed into four seasons.1 Although spring showed the lowest number of incidents (n = 1,111), there was no statistical differences between the seasons (summer = 1,264, fall = 1,364, winter = 1,480). There were also no mean differences between severity ratings during the different seasons. Analysis of assault locations showed that a large majority of altercations took place in the hallway (n = 2,491, 37.4%). Table 3 shows the number of assaults occurring in all locations. When looking only at the assaults leading to Level 3 or 4 severity classifications, the same three locations figure prominently. However, there was one more severe assault occurring in the bedrooms (n = 43, 28.1%) than the hallway (n = 42, 27.5%), and 29 severe assaults occurred in the day hall (19.0%).

Table 1.  Incidence and Severity of Aggressive Acts by Day of the Week. Frequency

Percentage

Average severity

682 798 804 742 822 784 587 5,219

13.1 15.3 15.4 14.2 15.8 15.0 11.2

1.22 1.21 1.16 1.16 1.22 1.21 1.22  

Sunday Monday Tuesday Wednesday Thursday Friday Saturday Total

Table 2.  Incidence and Severity of Aggressive Acts by Months of the Year. Frequency

Percentage

Average severity

509 486 485 389 374 348 339 484 441 477 442 445 5,219

9.8 9.3 9.3 7.5 7.2 6.7 6.5 9.3 8.4 9.1 8.5 8.5

1.19 1.18 1.19 1.26 1.22 1.17 1.20 1.18 1.19 1.20 1.21 1.20  

January February March April May June July August September October November December Total

Table 3.  Locations of Assaults.

Hallway Day hall Bedroom Dining room Other area Bathroom Grounds Office area Group room Medication room Unknown Total

Frequency

Percentage

1964 984 658 422 403 312 289 85 51 30 21 5,219

37.6 18.9 12.6 8.1 7.7 6.0 5.5 1.6 0.9 0.6 0.4  

Discussion The current study builds on previous violence incidence research by providing rates of inpatient aggression using a large sample. Furthermore, it expands these findings to incorporate information about injury severity. Overall, some findings were consistent with existing international

research. For example, there were notable increases in violence rates during busy meal, medication, and shift change times in our sample, similar to previous studies (Balderston et al., 1990; Weizmann-Henelius & Suutala, 2000). The current study also showed that patients were

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more commonly victimized than staff members. This ratio was comparable to the previous study conducted within a different California forensic hospital (Quanbeck et al., 2007). Importantly, differences from the previous literature were also found during the analyses. Most research had found that warmer months with more hours of sunshine had higher rates of aggressive acts. In the current study, the month with the highest incidence was January, a relatively cold month. Furthermore, both fall and winter showed more acts of aggression than summer and spring. Although California is well known for its temperate weather, the winter months often bring rain. Because grounds privileges are suspended during the rain and many recreational activities are cancelled, the increase in aggression may be related to many patients remaining on the housing unit without the opportunity for enjoyable activities. More patients remaining on the unit also increases the density of patients in the hallways and day halls. Indeed, Palmstierna, Huitfeldt, and Wistedt (1991) found that an increased number of patients on a unit significantly increased aggressive behavior, especially for patients who were diagnosed with a psychotic spectrum disorder. Alternately, the higher number of incidents in January and other winter months may be unrelated to weather factors and instead reflect disruptions in treatment schedules and staffing because of the holidays. Although only a trend with a small effect size was seen, the different rates of severe aggression on weekdays versus weekends may point to the importance of structured activities, reliable routines, and the presence of clinical staff during the weekdays. These same routines can be interrupted by staff member vacations and cancelled treatment opportunities during a period of time already made stressful because of frequent reminders of hospitalization instead of community living. Daffern et al. (2003) found that acute units had higher rates of aggression than long-term units. This finding was consistent with the belief that acute units often have the most symptomatic patients, whereas longer term units tend to have patients whose symptoms have remitted at least somewhat due to a consistent treatment environment. In the current sample, the acute units did show a higher incidence of aggression than long-term units; however, this difference was not statistically significant and did not reflect any differences in severity. As discussed above, different units within the same hospital may have different patterns of victimization (Daffern et al., 2006). The dichotomous cut between long-term and acute units used in the current study may be masking important differences between units. Indeed, psychiatric symptom acuity could be related to admission units’ higher incidence rates but patient milieu may play as larger or even larger role than unit type. For example, the

hospital in this study has single-sex male, single-sex female, and co-ed units. The gender breakdown of a unit could greatly influence the aggression rate on one acute unit versus another. Although unit type is an important variable to include when considering rates of aggression, it may only be one of many factors impacting the prevalence of violence. The current study also highlights that aggressors and patient victims are similar on many key demographic features. Indeed, the current sample’s aggressors and victims had similar rates of antisocial personality disorder diagnoses, were close in age, and were typically committed to the forensic hospital under the same statutes. This finding lends some support to previous research on the use of risk assessment instruments for assessing inpatient aggression. Specifically, static, historical, factors such as previous violence or age may not reliably distinguish aggressive inpatients from victimized inpatients as well as dynamic factors (Desmarais, Nicholls, Wilson, & Brink, 2012; McDermott, Edens, Quanbeck, Busse, & Scott, 2008; Vitacco, Gonsalves, Tomony, Smith, & Lishner, 2012). The current study attempted to add to the existing literature by providing a focus on severity ratings for inpatient aggression. Because severe assaults can result in career ending injuries for staff, serious disruptions to patient treatment, as well as large financial burdens for inpatient facilities, this study used the Incident Management System’s four-level rating system. The results show that the swing shift saw more severe aggressive incidents than the morning or overnight shifts. This finding was consistent with Cheung et al.’s (1996) study that found more severe incidents in the afternoon. The reason for severe incidents to occur more often in the afternoons and early evenings is unclear. It is possible that frustrations from earlier in the day continue to brew and escalate over time until a serious aggressive act. Additionally, the lack of clinical staff after typical work hours may change the unit milieu. These findings suggest that the afternoons and evenings may require more structured activities or enhanced staffing to curb aggressive acts before they become serious. Relatedly, the current findings highlight that more serious incidents occurred when there were staff members working overtime. Although there was a small effect size for this finding, it raises important questions about the whether staff members working extended shifts may be less equipped to deescalate aggressive situations before serious consequences. The current findings do not allow further analyses to assess whether the proportion of overtime staff was higher on certain shifts. Indeed, future studies may be able to explore if the increased severity of afternoon assaults is related to a higher level of overtime staff on the swing shift.

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Bader et al. Interestingly, it does not appear that significantly more severe incidents took place in the relative privacy of patient bedrooms compared to hallways and day halls. These numbers may provide some indication of whether severe assaults are reactive, impulsive acts or preplanned and predatory in nature. Specifically, preplanned acts of serious aggression toward a targeted victim may be more likely to occur in bedrooms, away from staff member’s easy view. This would allow an assault to go on longer before intervention and potentially keep a perpetrator from receiving disciplinary consequences if the victim did not report the aggressor’s name. If this is true, it is possible that many of the severe assaults that took place in public areas are reactive, impulsive acts that have not been planned. Indeed, there may not be a link between severity and motive. On the other hand, severe assaults that take place within the view of numerous patients and staff members maybe be planned as a message to others about a patient’s role on the unit, staff members’ inability to manage some patients, or unpaid debts for trading goods or services. In these situations, the choice of a public area for a planned assault shows an important relationship to the severity. In conclusion, these findings hold several notable clinical implications. First, these results underscore the clinical and empirical relevance of severity as a factor to be considered in the conceptualization of inpatient aggression. Severity of aggression has received minimal attention in the literature and warrants further examination. Second, these findings reinforce the point that psychiatric inpatient aggression is a heterogeneous, dynamic phenomenon with unique correlates and trends that differentiate it from community aggression. The trends discussed in this study can be incorporated into clinical practice in the hopes of minimizing areas of increased risk for aggression. Psychiatric inpatient facilities are limited in staffing and clinical resources; therefore, increasing the knowledge of time, location, and victim factors associated with aggression allows facilities to more effectively and efficiently utilize its limited resources. Finally, this study contributes to the body of inpatient aggression research that brings attention to unit and institutional factors (e.g., temporal, location, and staffing ratios) that are often more modifiable than patient factors (e.g., diagnosis, antisocial behaviors, cognitive impairment) in reducing inpatient aggression.

Limitations and Future Directions Utilization of the Incident Management System limited the data available for some analyses in this study. For example, no information about staff member victims’ age, gender, or years of experience is collected, making it impossible to replicate previous studies examining those

factors. Additionally, previous studies have identified the potential for underreporting when existing administrative procedures are used to capture aggressive events (Cheung et al., 1996). This potential for underreporting is present in the current study as well. Indeed, there is a possibility that certain types of aggression, certain victims, or certain locations may be more prone to underreporting than others. Last, this study relied on an idiosyncratic, administrative method of characterizing severity. Although this four-level system is clear and useful, future research may benefit from the use of a more widely used measure of severity, such as the Staff Observation of Aggression Scale. In spite of these limitations, the current study was able to report some key findings about aggression rates with a very large sample and present some valuable data regarding the severity of aggressive acts. Numbers of aggressive incidents per day and staff injuries can be easy to count; however, the other burdens associated with violence and aggression in the psychiatric hospital setting, such as decreased productivity and work satisfaction, significant disruption of the treatment environment, and a negative atmosphere in the milieu, are often more difficult to capture (Daffern et al., 2003). Consequently, prevention of aggression needs to be the focus of risk management activities. Author Roles Dr. Bader and Dr. Evans led the data acquisition and analyses. Dr. Welsh assisted with literature review and writing.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

Note 1.

Based on solstice and equinox dates.

References Arango, C., Calcedo Barba, A., Gonzalez-Salvador, T., & Calcedo Ordonez, A. (1999). Violence in inpatients with schizophrenia: A prospective study. Schizophrenia Bulletin, 25, 493-503. Balderston, C., Negley, E., Kelly, G., & Lion, J. (1990). Databased interventions to reduce assaults by geriatric inpatients. Hospital and Community Psychiatry, 41, 447-449. Cheung, P., Schweitzer, I., & Tuckwell, K. C. (1996). A prospective study of aggression among psychiatric patients in rehabilitation wards. Australian and New Zealand Journal of Psychiatry, 30, 257-262.

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Aggression Among Psychiatric Inpatients: The Relationship Between Time, Place, Victims, and Severity Ratings.

The rate of aggressive acts perpetrated by psychiatric inpatients remains a pressing issue. To date, few studies have distinguished between incident s...
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