Running head: AGGRESSION AND INTERVENTIONS

Adolescent Aggression and Restrictive Interventions
Vanessa L. Moe
Arizona State University

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Abstract

Seclusion and restraint are restrictive interventions that continue to be used in both physical care
and mental health care settings as a means of controlling dangerous behavior such as aggression.
Restrictive interventions place patients and healthcare staff in hostile situations that can lead to
physical, mental, and emotional injuries that can last a lifetime. Unfortunately, restrictive
interventions continue to be used in many healthcare organizations around the world and the
number of patient and staff injuries continue to rise. Stakeholders at a Phoenix area psychiatric
inpatient hospital conducted an internal audit on the number of seclusion and restraint episodes
in 2019, which revealed an increase in the number of seclusion and restraints episodes on the
adolescent unit. The result of this audit led to the project question: For nurses on an acute
adolescent inpatient unit, is a seclusion and restraint education program more effective than usual
practice in changing the knowledge and attitude regarding seclusion and restraint? The purpose
of this practice change project was to provide staff education that focused on trauma informed
care, de-escalation techniques, and therapeutic communication to improve staff confidence to
ultimately lead to the reduction of seclusion and restraint use on an adolescent inpatient unit. A
pre and posttest questionnaire designed to better understand nurse attitude and knowledge
regarding restrictive interventions prior to the education session was provided. A convenience
sample of nurses (N=9) participated in the project. The findings from the pre and posttest
questionnaire suggest that seclusion and restraint education for nurses may improve nurse
knowledge and attitude regarding the use of restrictive interventions and reduce rates of use.

Keywords: Adolescent, Aggression, behavior management programs, inpatient,
restrictive interventions, restraint, seclusion.

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Adolescent Aggression and Restrictive Interventions
The problem of restrictive interventions is a well-documented issue in behavioral health
inpatient healthcare organizations. Restrictive interventions have been used to protect the patient
and staff from behaviors that are deemed a danger to self, others, or property. Restrictive
interventions can range from physical, mechanical, or chemical restraints and include seclusion
or segregation from others (SAMSHA, 2011). Restraints are defined as any physical,
mechanical, or chemical means of immobilizing or restricting a patient’s freedom of movement
while seclusion is considered the involuntary confinement of a patient (SAMSHA, 2011). For
many decades, restrictive interventions have been used for safety and not as a form of treatment
(Lai, 2007). However, these interventions expose patients, as well as staff, to physical and
emotional pain, trauma, and injuries. Therefore, the benefits associated with the use of restrictive
interventions continue to be heavily debated topic and the question remains; are they truly an
effective and therapeutic intervention? (Lai, 2007).
Problem Statement
Seclusion and restraint (S/R) continue to be utilized as a therapeutic intervention around
the world throughout various psychiatric settings. Studies have shown that approximately 20% of
inpatient psychiatric patients hospitalized worldwide are physically restrained for aggressive
behaviors and patients under 12 years old are the most commonly restrained patient (Pazargadi et
al., 2013; SMASA, 2012). According to the Crisis Prevention Institute (CPI) and the Substance
Abuse and Mental Health Services Administration (SAMHSA), 37.5% of patients under the age
of 18 have experienced S/R in one way or another and approximately 50-150 American patients
die annually because of S/R. Since the reporting of adverse events associated with S/R was not
mandated prior to 1998, the exact number of injuries and deaths associated with S/R is unknown

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(General Accounting Office (GAO, 1999). However, since 1999, reporting records and evidence
has continuously shown that both patient and staff injuries continue to occur as a result of S/R
use (Haimowitz & Urff, 2006; GAO, 1999; Moylan & Cullinan, 2011). Despite these alarming
statistics, S/R continue to remain a fixed intervention in the management of hostile and
aggressive behaviors (Wynn, Kvalvik, & Hynnekleiv, 2011).
Purpose and Rationale
Restrictive interventions can be detrimental to the health, safety, and recovery of patients
with mental health conditions. S/R events can cause physical, mental and emotional injuries that
affect patient outcomes. Ensuring good patient outcomes requires identification of evidencebased interventions that are focused on quality of care, patient safety, and prevention of adverse
events. Therefore, it is imperative that high quality, evidence-based interventions are developed
and implemented into practice. The purpose of this evidence-based practice (EBP) paper is to
review past and current literature that identifies the most common behaviors associated with
restrictive interventions, to discuss the dangers associated with S/R, and to examine alternative
interventions that proactively manage difficult patient behaviors.
Background and Significance
In attempts to minimize the use and dangers associated with S/R, many organizations
have implemented practice guidelines and recommend using S/R as a last option for aggressive
behaviors. There is evidence to suggest that evidence based therapeutic alternatives for the
management of aggressive inpatient behavior is possible. Behavioral modification techniques
such as Collaborative Problem Solving (CPS), Cognitive Behavior Modification (CBM), and
Management of Aggressive Behavior (MAB) have been shown to be effective the management
of difficult behaviors such as aggression (Erocole-Fricke et al., 2016; Price et. Al (2017). Staff

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education and training to improve de-escalation techniques, enhance therapeutic communication,
and promote recovery focused environment are essential for establishing a restraint free
healthcare organization (Delaney, 2006).
According to The Substance Abuse and Mental Health Services Administration
(SAMSA), 82% of children and youth have experienced a traumatic event in their lifetime, 41%
have had thoughts of suicide, and 23% have attempted suicide in the past (2012). Treatment
initiatives such as the national Children’s Mental Health Initiative (CMI) focuses on improving
mental health care support and treatment for children and youth with emotional or mental
disturbances (SAMSA, 2019). Untreated mental issues leave children and youth at an increased
risk for substance use and abuse, suicidal ideations, and impulsive decisions that can impact their
future (Carr, et al., 2008).
Children and adolescents displaying aggressive behaviors are commonly seen in acute
inpatient psychiatric settings. Studies have shown that 60% of all child and adolescent
psychiatric hospital referrals are for the assessment and treatment of aggression (Dean et al.,
2008; Hage et al., 2009). According to previous research, 40% of adolescent patients have
displayed various acts of aggression while inpatient which include verbal hostility, physical
assaults, and property damage (Renwick et al., 2016; Barton et al., 2001; Dean et al., 2008).
Although aggressive behaviors are the cause for many psychiatric admissions, many patients
with aggression will continue to have aggression outbursts throughout their hospital stay. Often,
the circumstances surrounding the admission conditions such as unit confinement, length of stay,
and lack of patient autonomy increase patient agitation and aggression (Wong et al. 2016; Baeza,
2013). As a result, patients with aggression can be challenging and difficult to treat.

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There are several studies that have shown positive effects of managing inpatient
aggression with therapeutic techniques based upon other than S/R. For example, a study
completed in Canada found that training staff with the Omega Program for the Management of
Aggressive Behaviors (OPMA) effectively reduced the frequency and duration of S/R in an
inpatient setting and a similar study utilizing OPMA found that posttest qualitative results
showed less psychological stress on the patient with an increased level of confidence in using
coping skills to control anger after discharge (Geoffrion et al., 2018). Another study by Booker et
al., found that training inpatient staff with Occupational Mindfulness (OM) training had helped
staff respond more positively and mindfully to patients displaying challenging and aggressive
behavior which ultimately lead to a decrease in the use of S/R (2014). Other studies have found
that multi-modal approaches based upon the six core strategies have been effective in managing
aggressive behaviors and reducing S/R in inpatient settings which include the incorporation of
organizational changes, staff training in aggression prevention, collaborative treatment planning
with patient involvement, and including aggression risk assessments at admission (GuzmanParra et al., 2016; Label et al., 2014; Wieman et al., 2014).
Studies have reported patient perceptions and experiencing during the use of S/R. A study
completed by Kontio et al. found that patients expressed feeling punished, distressed, and
uninformed during the process while others reported that improvements could be made by
offering alternatives to S/R and providing more appropriate programming (2012). Other studies
have found that patients express feelings of fear, powerlessness, and humiliated during S/R but
also report patients expressing feelings of safety if appropriate staff presence, calmness, and
explanation were provided during the process (Chien et al.2015; Lanthen, Rask & Sunnqvist,
2015; Price et al.,2016). Studies have also shown that staff perception of S/R include reluctance

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in using S/R, however, have little confidence in alternative measures that are effective in
controlling aggressive behavior but also report feeling that increased use of S/R is associated
with undertrained staff members in de-escalation techniques as well as inadequate staff to patient
ratios (McCann et al. 2014; Mohler & Meyer, 2014). Furthermore, a study by Pazargadi et al.
found that patients and nurses contribute to a negative nurse-patient relationship and consider
this as a barrier to the reduction of aggression and that education to improve relationships would
be beneficial for optimal patient outcomes (2015).
Usual care in psychiatric settings consist of various forms of crisis prevention techniques
that include annual training and refresher courses that teach psychiatric staff how to safety
execute S/R. For example, programs such as the Crisis Prevention Institute (CPI) have been
implemented in various settings as a means of training staff on nonviolent crisis interventions
(2016). CPI teaches de-escalation skills as part of an 8-hour training which also instructs staff
how to safely administer S/R in emergency and psychiatric settings (CPI, 2016). Given that this
is a one day, 8-hour annual training, many staff are not adequately trained to de-escalate or
therapeutically communicate with agitated patients (Guzman-Parra et al., 2016; LeBel et al.,
2014). In order to effectively manage acute aggression, there must be more frequent training
programs for evidence-based aggression management techniques that help staff members
appropriate manage aggressive patients and reduce the use of S/R for better patient outcomes.
Overall, important themes in the given literature describe R/S as a dangerous intervention
for management of aggression that affects both patients and staff members. Staff and patient
injuries, including death, are significant adverse events related to S/R that can be significantly
reduced and even eliminated by the incorporation of multi-modal evidence-based aggression
management programs in inpatient settings. Themes in recent research have shown that the

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combination of various therapeutic interventions and techniques have made effective multimodal aggression programs successful in reducing aggression and decreasing the utilization of
S/R. Therefore, it is imperative to continue research on this topic and discover innovative
strategies to safely and effectively manage patient aggression to reduce and eliminate S/R while
providing better patient experiences and improved patient outcomes.
Internal Evidence
Stakeholders at a local Arizona hospital have been looking at staffing shortages, staff
injuries, and more specifically, the relationship between patient acuity and patient aggression.
Stakeholders have been monitoring the number of incident reports, staff injuries, and work injury
claims in correlation with the increasing number of physical restraints that have been occurring
on the adolescent inpatient units. The internal evidence suggests that there is an increase in the
number of physical restraints occurring and stakeholders are seeking solutions to reduce the
number of physical restraints on the adolescent units
There are many treatment considerations when working with children. Providers must
work together to improve mental health outcomes. It is important to screen children and
adolescents for mental health conditions, specifically aggression prior to admission to an acute
inpatient setting. Being aware of possible dangers associated with patient aggression can help
prevent and protect patients and staff from unnecessary injuries and use of restraints (Berring,
Pederson & Buus, 2016). Utilizing innovative and evidence-based aggression management
programming on an adolescent unit can improve the therapeutic milieu while teaching skills that
can be applied in the community for better patient outcomes. Therefore, the concern related to
increased use of restraints as a result of adolescent aggression in an impatient setting has led to
the PICOT question: For nurses on an acute adolescent inpatient unit, is a seclusion and restraint

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education program more effective than usual practice in changing the knowledge and attitude
regarding seclusion and restraint?
Sources and Search Strategy
An exhaustive search was conducted in three different electronic academic data databases
that included the PubMed database, ProQuest Psych Info Database, and EBSCOhost CINAHL
search database. Key words used to search each database included adolescents, aggression,
mental health inpatient, restraint, seclusion, de-escalating techniques, improved outcomes,
interventions, and behavior management strategies. These terms were search in various
combinations and individually with limiters of full text, English language, peer reviewed,
research articles. The search modes utilized included MESH terms with Boolean connectors and
word-controlled vocabulary.
PubMed search results initially revealed 1547 articles when searching for adolescent,
mental health, and aggression. When narrowed and sorted for best match with the term’s
adolescent aggression, interventions the final number of articles yielded was 44 articles. Upon
searching the combined terms adolescent and restraint and inpatient, Psych Info produced 282
articles. Upon narrowing the search to combine adolescent, restraint, inpatient, and behavior
management, 35 articles remained and were included in the final article count.
The initial EBSCOhost CINAHL search query results included 590 articles when
searching the terms adolescent, hospitalization, aggression, and behavior management strategies.
The final search terms restraints or physical restraints combined with adolescents or teenagers or
young adults, and inpatients, hospitalization, or hospitalized patients produced 70 article results
for the final search. Grey literature for restraint statistics and guidelines was collected from The

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Joint Commission on Quality and Safety, The Centers for Medicaid and Medicare Services, and
The Substance Abuse and Mental Health Services Administration websites.
Critical Appraisal and Synthesis
The Melnyk and Fineout-Overholt’s (2011) rapid critical appraisal (RCA) tool was used
to evaluate and select the10 articles for the literature review (Appendix A). The selected articles
selected were of high-level evidence with most of the articles being randomized control trials
(RTC) (Appendix A). The additional articles included one pilot study, one quality improvement
study, and one quantitative study (Appendix A). The remaining two articles were qualitative
studies (Appendix A). Only one article did not report their funding source and the majority were
funded by national research institutes around the world. Singh et al. (2016) was the only study to
declare a bias since the intervention was developed by one of the article’s author’s; however, the
author’s declared that the study was not funded and completed without any financial or
commercial relationships that put the study at risk for any conflict of interest (Appendix A).
All studies had appropriate samples sizes according to the study type. Pazargadi et al.
(2015) was the only study with a relatively small sample size, however, it was appropriate and
adequate given the fact that it was a qualitative study with purposive sampling (Appendix A).
Eight of the studies were conducted in a psychiatric inpatient unit in a community-based
psychiatric hospital setting with focus on interventions to prevent or reduce seclusion and
restraint use. Two studies were conducted outside of a psychiatric inpatient unit. Franco et al.
(2016) completed their study in a public high school setting and Testad et al. (2015) completed
their study in a nursing home setting; however, both studies focused on interventions to prevent
and reduce seclusion and restraint use (Appendix A).

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There was a significant homogeneity found between the 10 studies. Most of the studies
were inclusive of adults, both men and women, diagnosed with psychiatric conditions while
admitted to psychiatric inpatient settings. Testad et al. (2015) was the only study to focus on the
geriatric population diagnosed without a psychiatric condition; however, the study remains
applicable because the patient behaviors associated with dementia are like those with psychiatric
conditions and often require behavior management interventions (Appendix A). There was also
significant homogeneity found between study outcomes in which ten out of ten studies found
their interventions to be successful in decreasing the use of S/R in sample populations. As the
homogeneity shows a significant effect on the decreased rate in the use of restrictive measures, it
is also important to recognize the significance of heterogeneity observed in the measurement
tools and intervention designs.
Eight out of ten of the studies used different measurement tools and types of interventions
to arrive at the same outcome; a decrease in the use of restrictive measures. The qualitative
studies by Price et al. (2017) and Pazargai et al. (2015) were the only studies to use semistructured interviews as measurement tools (Appendix A). Despite the heterogeneity of
measurement tools and interventions, many commonalities exist between each study. For
example, they all focus on various forms of staff and caregiver education, training, and behavior
management techniques. Additionally, the important theme found across all studies was the
focused on aggressive behavior. Therefore, it is possible to assume that that the proactive
assessment and prediction of these behaviors contributed to the reduction of seclusion and
restraint use in each study.

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Conclusion of Evidence Synthesis
The outcome of the literature review provided substantial evidence that the management
of aggression and agitation can be effectively managed without the use of seclusion and restraint.
Not only did every study show that noninvasive behavior management of aggression is possible
but also provided additional evidence showing that effective behavior management can also
reduce the use of emergency medication administration, decrease patient and staff injuries, and
reduce staff turnover. While every study used a different interventional approach, all studies
effectively demonstrated that noninvasive and less restrictive behavior management approaches
are effective, regardless of the population or setting. This evidence provides valuable information
that can be used to implement practice change at many different levels within the current
healthcare system and it can aid in the improvement of patient health outcomes.
Theoretical Framework
The theoretical framework for this project was the Theory of Planned Behavior (TPB).
The TPB approach links an individual’s beliefs and attitudes with behavior. The theory proposes
that human behavior is influenced by behavioral beliefs, normative beliefs, and control beliefs
(Ajzen, 2019). According to this theory, behavioral beliefs impact an individual’s favorable or
unfavorable attitude towards a given behavior, normative beliefs are the social pressures to
perform a behavior, and the control beliefs are agents that facilitate or impeded performance of
the given behavior (Ajzen, 2019). The assumption is that the more favorable the attitude is,
combined with significant increase in social influence and perceived behavior control, the greater
the intent will be to perform a given action (Ajzen, 2019). This assumption will then result in the
expectation that a person will execute the intended behavior when the opportunity arises. This
theory was an effective framework for the proposed study since the study measured staff

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attitudes and beliefs associated with the use of restrictive interventions in an inpatient psychiatric
unit.
Implementation Framework
The PRECEED-PROCEED model guided this project. This model provided a
comprehensive model for both assessing health needs while designing and implementing
interventions that influence positive health outcomes (Crosby & Noar, 2011). The PRECEDE
framework begins by focusing on the development of a behavioral diagnosis of a social problem
before the development of the intervention plan. This includes determination of the severity of
health issue at hand, the behaviors of the individuals who directly affect the patients at risk, and
the actions of those that impact the individuals at risk (Crosby & Noar, 2011). Once this is
established, specific and effective interventions can then be identified to assist with changing the
problem at hand. The PROCEED area of this model includes implementation of the intervention
chosen and outcome evaluation can be measured (Crosby & Noar, 2011). This theoretical
framework aligned with the project since the undesired behavior was identified as the increase
use of seclusion and restraint practices by inpatient staff. Once established, the intervention and
goal to decrease the use of restrictive measures was determined. This includes an educational
presentation regarding the risks, dangers, and trauma associated with behavior containment
methods, such as seclusion and restraint, and effective de-escalation techniques for difficult
patient behavior. The project facilitator administered a pre and post questionnaire to evaluate and
compare staff attitudes and knowledge towards managing disturbed psychiatric patients before
and after the educational presentation.
Methods

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This project was approved by the institutional review board at Arizona State University. It
was conducted with nurses working on an adolescent acute inpatient unit at a suburban behavioral
health hospital in the southwest region of the United States. Nurses were English speaking, over
18 years of age, able to attend education sessions, and completed 2 project questionnaires.
Exclusions included anyone that was not a nurse, or the primary unit was not the adolescent
inpatient unit. The adolescent unit supervisor informed nurses at a staff meeting of the project
and provided a sign-up sheet that was posted in the staff break room for willing participants to
sign up for the project. A flyer was also posted in the staff break room with project information
and contact information for questions or concerns. The Co-PI contacted the willing participants
to arrange a time to complete the questionnaires. All questions were answered during this time
and all participants agreed to participate in the project without credit or any compensation for
participation. Participants were asked to complete a consent form that contained a unique ID
consisting of the last two digits of their birth year and the two digits of their birth month to
compare pre and post intervention questionnaire data. The consent was provided immediately
prior to the completion of the prequestionnaire and participants signed and dated their consent
forms.
The participant educational session was approximately 30 minutes long and was
developed and performed by the CO-PI under the PI. The information during the education
session included background information regarding the use of seclusion and restraints,
definitions, level of current knowledge, and indications for use as well as policy, initiatives, and
dangers associated with use of restrictive intervention practices. Two weeks after the education
session, participants were given a post intervention questionnaire. The data collection period
lasted 1 month and there was no long term follow up required. The consent forms and both pre

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and post intervention questionnaires were locked in a separate file cabinet for safe keeping.
Results were stored until May 2020 after the results were analyzed and the study was completed.
Intellecus Statistical Analysis Software was used to store, manage, and analyze the data.
Descriptive statistics were used to describe the sample and outcome variable. To evaluate the
pre-intervention and post-intervention responses, a paired sample t-test was used to analyze data
and identify any increase in knowledge and change in attitude towards S/R practices.
Participants that became psychologically upset after learning the dangers associated with
S/R or those that may not have agreed with the education provided were instructed to contact
their unit supervisor or employee assistance program (EAP) for psychological assistance. The
results of this project contributed to the improvement in patient outcomes in the acute adolescent
mental health treatment approach to treatment. By educating staff on the way care is delivered it
helped reduce the need for restrictive interventions. There was limited foreseeable risks
associated with this project. There was no outside funding provided for this project and the
project budget was completed with the COPI as the main funding source.
Outcome Measurements
The Nurse Knowledge and Attitude Questionnaire (NKAQ) is a forty question, 4-part
questionnaire that was used to assess nurse baseline knowledge and attitudes related to the use
of seclusion and restraint practices (Kahlil, 2017). Permission from the creator of NKAQ was
obtained for the use of this instrument. The NKAQ included demographic questions that
include gender, age, ethnicity, and educational and work experience. The second part was
comprised of 15 questions regarding S/R definitions, purposes, indications, as well as ethical
issues, nursing care for restrained patient, and alternative interventions. Correct responses were

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given a score of 1 and incorrect responses were given a score of 0, with ‘undecided’ answers
included in the incorrect category with a potential scoring range of 0–15 (Kahlil, 2017).
The third part contained 11 questions to measure nurse attitudes towards S/R. Using a 3point Likert scale, each item was given a score of 3 for agree, 1 for disagree, and vice versa for
negatively phrased items (Kahlil, 2017). High scores were reflective of favorable and positive
attitudes towards S/R while low scores were reflective of negative attitudes. The score range for
this section was 11-33.
The fourth part consisted of 14 questions that assessed nursing practice regarding S/R.
This section addressed alternative interventions prior to S/R use, indications for S/R, physician
order and documentation requirements, and staffing levels contributing to the increased use of
S/R practices (Kahlil, 2017). Participants were asked to respond to each of the items on a 3-point
Likert Scale about whether they always, sometimes, or never performed these practices. Most
items were reflective of more favorable practices towards caring for restrained patients, with
scores of 3 for always to 1 for never having adopted such practices (Kahlil, 2017). The negative
item was reverse-scored. Therefore, a score of 14 indicated the most undesirable practice while
42 indicated the best practice in use of restraints (Kahlil, 2017).
Results
The average score for the post test results showed that trauma informed education
increased nurse S/R knowledge and change attitudes about restrictive interventions. This is
clinically significant as this may help decrease future use of S/R practices on the adolescent
inpatient unit while helping to create an organizational culture change that is supportive of a
restraint free environment. However, in order to sustain change and reduce S/R practices,
ongoing trauma informed education sessions focusing on de-escalation techniques, therapeutic

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communication, and alternative interventions should be implemented and continuously evaluated
for effectiveness. This will help not only improve patient care and health outcomes, but it will
decrease staff and patient injuries, save the health care system unnecessary costs, and help
contribute to finding effective alternatives. These positive outcomes can then be used to advocate
for policy implementation to regulate and eventually eliminate restrictive interventions.
Discussion
Implementation of evidence-based interventions designed to reduce aggression, agitation,
and other dangerous behaviors of adolescent patients admitted to psychiatric inpatient unit would
have a significant impact on patient care, staff satisfaction, and healthcare outcomes around the
world. The development of nurse education programs focused on trauma informed care,
therapeutic communication, and de-escalation techniques may significantly decrease the rate of
adverse events associated with seclusion, restraint, and other restrictive measures. The
incorporation of trauma informed educational programs may also help change the organizational
culture to a more therapeutic, supportive, and humanistic approach to treatment. Therefore, it is
important to establish an effective program that is designed to decrease patient agitation,
aggression, and other dangerous behaviors to decrease the use of restrictive measures that place
patients and staff in dangerous situations. Projects such as this help aid in the search to find
innovative, evidence-based interventions that are safe and effective.
Current practice in the management of aggression in the mental health setting continues
to result in the use of restrictive measures. This not only places patients and staff in dangerous
situations but it results in poor patient care and high staff turnover rates. By implementing
programs such as nurse education sessions designed to increase knowledge and change attitudes
towards S/R with help prevent injuries, improve patient care, and enhance mental health

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treatment. Implementation of this project will help contribute to the efforts in finding alternative
evidence-based interventions that aid in the overall improvement of patient outcomes. However,
implementing projects in search of evidence-based alternatives is not always easy.
There were two barriers encountered during the implementation of this project. The first
barrier occurred during the post testing period when the organization had switch restraint training
companies. This required all staff to attend a one day, eight-hour training that included education
on S/R practices, de-escalation techniques, and therapeutic communication. This may have
impacted the project outcomes since nurses received additional education during the
implementation phase of this project. The second barrier to this project was that the project site
implemented an auto accept process for accepting patients without a chart review. This may have
impacted the project since more difficult and aggressive patients were being admitted to the
adolescent inpatient which resulted in an increase in S/R practices. The challenges associated to
this project were unique and not found in any other literature review results. Therefore, projects
targeting nurse education, therapeutic communication, and de-escalation techniques should
continue to be developed, implemented, and evaluated throughout various settings to identifying
safe alternatives, improve patient outcomes, and advocate for policy regulation on S/R practices.

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Running head: AGGRESSION AND INTERVENTIONS

24
Appendix A

Table 1
Evaluation Table
Citation
Bowers et
al., (2015)
Reducing
conflict and
containmen
t rates on
acute
psychiatric
wards: The
Safewards
cluster
randomized
controlled
trial.
Country:
United
Kingdom
Funding:
National
Institute of
Health
Research.
Bias: None
declared

Theoretical
Framework
Inferred
Behaviorist
Theory

Design/Purpose

Sample/Setting

Design: A
Pragmatic
randomized
controlled trial.
Purpose: To
reduce conflict
on IPU through
interventions that
could enhance
staff modifiers.

N: 15 hospitals
N: 31 IPU
n: 9 NHS
Setting: PIU in
London
Demographics:
Inclusion: IPU
for adults of
any gender,
willing
healthcare
professionals.
Mean Age:33.7
Female: 59.4%
Exclusion: If
specialty unit,
planned major
unit changes, no
unit manager,
>30% nursing
vacancy rate.
Attrition: 0

Major Variables &
Definitions
IV: Safewards
Intervention training
Package
IV Def: 10 various
behavior
interventions
DV1: Conflict
DV2: Containment
events

Measurement

Analysis

PCC
Patient-staff
Conflict
Checklist
(PCC)- total
conflict and
rates of total
containment
(APDQ)
Attitude to
Personality
Disorder
Questionnaire
Self-harm
Antipathy scale
Ward
Atmosphere
Scale

Poisson
hurdle mixed
model.

Findings/
Theme
DV1: reduced
the rate of
conflict events
by 15.0% (95%
CI 5.6–23.7%).
P=0.001
Control
(95% CI 5.6–
23.7%) relative
to the control
intervention. by
26.4% (95% CI
9.9–34.3%)
DV2:
26.4% (95% CI
9.9–34.3%).
P=0.001
ES:
.54 = Large

Decision for Use
LOE: 2
Strengths: Large
population size, advanced
registration, independent
randomization, independent
and blinded statistical
analysis.
Weakness: Limited to
general IPU, different staff
qualifications, and
education levels.
Conclusions:
The rate of containment
events for the experimental
intervention was reduced
the experimental condition
reduced the rate of conflict
events by 15%.
Feasibility: This
intervention can be used in
further testing with different
populations and settings.

Key: A - adolescents, AG - agitation, AGG - aggression, AP - Agreement to participate, B - bachelor, B - boys, BI - behavioral indicators, BSN- bachelor degree in nursing, CCD - comprehensive
care delivery, CD - control and dominance, CE - coercive interventions, CD - communicative process, D- de-escalation, DI - duration of intervention, DQ- delinquent behavior, DT - de-escalation
techniques, E - environmental EB - escalating behavior, EBT - evidence based treatments, EI - Environmental Influences EL - education level, EPB - escalating patient behavior, EPN - years in
psychiatric nursing, ES - effect size, FAC - factors affecting connections, FCO - failure to communicate with others, FMHC - finnish mental health act, G - girl, SI - inpatient, ICS- insufficient
communication skills, IL - interview length, IMM - intramuscular injectable medication, IO - increased observation, IP - interpersonal process, ITP - individual treatment plans, LNP- large number of
pts, LOK - lack of knowledge, LSRC- lack of staff respect for culture, M - mean, Mdn - median, Mo - mode, MPS - manpower shortage, MSN - masters education in nursing, N - no, N - population
size, n - sample size, NA- negative attitude, NC - # of pts in control group, NI - # of pts in intervention group, NPB - nurse patient barriers, NPC - negative personal characteristics, NPR - nurse
patient relationship, NPR - nurse patient relationship, NRV - nurse related variables, OBC - organizational behavior change, OBP - organizational barriers to relationship between nurse and pts, ORV
- organizational variables, P - psychopathological, PH - physical hold, PIU - psychiatric inpatient unit, PMT - parent management training, PPB - patient perspective barriers, PPE - patient perspective
enablers, PR - physical restraint, PRB - patient related variables, PRNM - PRN medication, PRU - patterns of restraint use, Pts- patients, PV - physical violence, PW - psychiatric ward, R - restraint,
Ra -Range, RP - restrictive practices, RRI - restraint reduction initiatives, RU - restraint utilization, S - seclusion, SD - standard deviation, SUR - service user researcher , TF - time frame, TR therapeutic relationship, WE - work exhaustion, WO- work overload, Y - yes

AGGRESSION AND INTERVENTIONS
Citation
Citation
Blair et al.
(2016).
Reduction
of
seclusion
and
restraint in
an inpatient
psychiatric
setting: A
pilot study.
Country:
USA
Funding:
Burlingame
Center for
Psychiatric
Research
and
Education,
The
Institute of
Living,
Hartford
Hospital,
Bias: None
declared

Theoretical
Framework
Theoretical
Framework
Inferred:
Theory of
Planned
Behavior

25

Design/Purpose

Sample/Setting

Design/ Purpose

Sample/Setting

Design: Pilot
study
Purpose: a
quality and
safety initiative
designed to
decrease
seclusion/restrai
nt (S/R)

N: 120
n: 3884
Setting: PIU
Attrition: None
Demographics:
B 12 years old,
85.9 % 13–65
and 9.2 % C 66;
49.7 % of
patients were
female and
50.3 % male;
race distribution
was 15.9 %
black, 23.9 %
Spanish/Hispani
c, 56.3 % white,
and 3.9 %
other. (n =
8029) was
5.0 % B 12
years old,
87.2 % 13–65
and 7.8 % C 66;
48.5 % of
patients were
female and
51.5 % male;
race distribution
was 16.5 %

Major Variables &
Definitions
Major Variables &
Definitions
IV: Risk
Connections training
DV1:
violence/aggression
DV2: Restraint
DV3: Seclusion
BVC: Brøset
Violence Checklist

Measurement

Analysis

Measurement

Analysis

BVC Checklist
instrument

Chi-Square
T-test

Findings/
Theme
Findings/
Theme
DV1: BVC 2.58
score (high risk
aggression/viole
nce)

DV2: Rates of
restraint events
decreased 6 %
(nonsignificantly, p =
0.44): baseline
213/3884 =
5.5/100
admissions,
study period
412/8029 =
5.1/100
(p < 0.01).
DV3: study
period 213/8029
= 4.4/100
admissions vs.
baseline
358/3884 =
9.2/100
admissions, p
0.01), a 52 %
reduction
ES: Small .10

Decision for Use
Decision for Use
LOE: 3
Strengths: Large sample
size, numerous variables.
Weaknesses:
One hospital used. Small
effect size
Conclusions:
Intervention was effective
in reducing use of S/R
events and duration time.
Feasibility:
This pilot study can be used
in a variety of settings and
in an adolescent unit to
reduce S/R.

Key: A - adolescents, AG - agitation, AGG - aggression, AP - Agreement to participate, B - bachelor, B - boys, BI - behavioral indicators, BSN- bachelor degree in nursing, CCD - comprehensive
care delivery, CD - control and dominance, CE - coercive interventions, CD - communicative process, D- de-escalation, DI - duration of intervention, DQ- delinquent behavior, DT - de-escalation
techniques, E - environmental EB - escalating behavior, EBT - evidence based treatments, EI - Environmental Influences EL - education level, EPB - escalating patient behavior, EPN - years in
psychiatric nursing, ES - effect size, FAC - factors affecting connections, FCO - failure to communicate with others, FMHC - finnish mental health act, G - girl, SI - inpatient, ICS- insufficient
communication skills, IL - interview length, IMM - intramuscular injectable medication, IO - increased observation, IP - interpersonal process, ITP - individual treatment plans, LNP- large number of
pts, LOK - lack of knowledge, LSRC- lack of staff respect for culture, M - mean, Mdn - median, Mo - mode, MPS - manpower shortage, MSN - masters education in nursing, N - no, N - population
size, n - sample size, NA- negative attitude, NC - # of pts in control group, NI - # of pts in intervention group, NPB - nurse patient barriers, NPC - negative personal characteristics, NPR - nurse
patient relationship, NPR - nurse patient relationship, NRV - nurse related variables, OBC - organizational behavior change, OBP - organizational barriers to relationship between nurse and pts, ORV
- organizational variables, P - psychopathological, PH - physical hold, PIU - psychiatric inpatient unit, PMT - parent management training, PPB - patient perspective barriers, PPE - patient perspective
enablers, PR - physical restraint, PRB - patient related variables, PRNM - PRN medication, PRU - patterns of restraint use, Pts- patients, PV - physical violence, PW - psychiatric ward, R - restraint,
Ra -Range, RP - restrictive practices, RRI - restraint reduction initiatives, RU - restraint utilization, S - seclusion, SD - standard deviation, SUR - service user researcher , TF - time frame, TR therapeutic relationship, WE - work exhaustion, WO- work overload, Y - yes

AGGRESSION AND INTERVENTIONS
Citation

Theoretical
Framework

Design/Purpose

Citation

Theoretical
Framework

Design/
Purpose

Pazargadi
et al.
(2015). The
therapeutic
relationship
in the
shadow:
Nurses’
experiences
of barriers
to the
nurse–
patient
relationship
in the
psychiatric
ward.
Country:
South Iran
Funding:
Deputy of
Research
Affairs of
Ahvaz
Jundishapu

Inferred
Peplau’s
Theory of
Interpersona
l
Relationship
s

Design:
Descriptive
Qualitative
content-analysis
study.
Method:
semi-structured.
Purpose:
To
investigate the
psychiatric
nurses’
experiences
of using physical
restraint in the
psychiatric
wards of Ahvaz
hospitals,
southern Iran.

26
Sample/Setting
black, 23.6 %
Spanish/Hispani
c, 55.3 % white,
and 4.6 % other
Sample/Setting
Purposive
sampling
method
N – 14
Age Ra: 25-52
M: 38.5
EPN Ra: 7
months-26 yrs.
EL: BSN 13,
MSN - 1
k
Setting: PIU
TF: 2012-2013
Inclusion:
1. EL – B
2. YP > 6
3. AP – Y
Exclusion:
unlisted
Attrition:
None

Major Variables &
Definitions

Measurement

Analysis

Findings/
Theme

Decision for Use

Major Variables &
Definitions

Measurement

Analysis

Findings/Theme

Decision for Use

Theme 1: NPB
affected by
NPC, WE, NA
Theme 2: PRB
affected by
LOK, FCO
Theme 3: OBR
affected by WO,
LNP, MPS
Findings:
TR is neglected
and in the
shadows of care.

LOE: 4
Strengths: Qualitative
design
Strong themes to improve
NPR.
Weaknesses:
No discussion of attrition
rate, amount of hospitals not
discussed, gender not
discussed.
Conclusions:
NPR can be improved by
focusing on NPB, PRB, and
OBR.
Feasibility: Results add
elements and characteristics
for improving NPR.

IV: Nurse -Pts
experience
DV1: NPB
DV2: PRB
DV3: OBR

Semi-structured
inpatient
interviews
recordings

Inductive
content
analysis

Key: A - adolescents, AG - agitation, AGG - aggression, AP - Agreement to participate, B - bachelor, B - boys, BI - behavioral indicators, BSN- bachelor degree in nursing, CCD - comprehensive
care delivery, CD - control and dominance, CE - coercive interventions, CD - communicative process, D- de-escalation, DI - duration of intervention, DQ- delinquent behavior, DT - de-escalation
techniques, E - environmental EB - escalating behavior, EBT - evidence based treatments, EI - Environmental Influences EL - education level, EPB - escalating patient behavior, EPN - years in
psychiatric nursing, ES - effect size, FAC - factors affecting connections, FCO - failure to communicate with others, FMHC - finnish mental health act, G - girl, SI - inpatient, ICS- insufficient
communication skills, IL - interview length, IMM - intramuscular injectable medication, IO - increased observation, IP - interpersonal process, ITP - individual treatment plans, LNP- large number of
pts, LOK - lack of knowledge, LSRC- lack of staff respect for culture, M - mean, Mdn - median, Mo - mode, MPS - manpower shortage, MSN - masters education in nursing, N - no, N - population
size, n - sample size, NA- negative attitude, NC - # of pts in control group, NI - # of pts in intervention group, NPB - nurse patient barriers, NPC - negative personal characteristics, NPR - nurse
patient relationship, NPR - nurse patient relationship, NRV - nurse related variables, OBC - organizational behavior change, OBP - organizational barriers to relationship between nurse and pts, ORV
- organizational variables, P - psychopathological, PH - physical hold, PIU - psychiatric inpatient unit, PMT - parent management training, PPB - patient perspective barriers, PPE - patient perspective
enablers, PR - physical restraint, PRB - patient related variables, PRNM - PRN medication, PRU - patterns of restraint use, Pts- patients, PV - physical violence, PW - psychiatric ward, R - restraint,
Ra -Range, RP - restrictive practices, RRI - restraint reduction initiatives, RU - restraint utilization, S - seclusion, SD - standard deviation, SUR - service user researcher , TF - time frame, TR therapeutic relationship, WE - work exhaustion, WO- work overload, Y - yes

AGGRESSION AND INTERVENTIONS
Citation

27

Theoretical
Framework

Design/Purpose

Sample/Setting

Major Variables &
Definitions

Measurement

Analysis

Findings/
Theme

Decision for Use

Theoretical
Framework
Theory of
Planned
Behavior

Design/ Purpose

Sample/Setting

Measurement

Analysis

N: 26
n :7 PIU
Age:
18-30: N =8
31-43: N = 11
44-60: N = 6
61+: N = 1
Female
Gender:
N = 18 (69%)
Male Gender:
N = 8 (31%)
RP: PR N = 17
(65%)
IMM: N = 11
(42%)
S: N = 9 (34%)
PRNM: N = 19
(73%)

Findings/
Theme
Theme 1:
Underuse of DT
attributed to LSR
Theme 2:
Need to retain
CD over pts.
Theme 3:
PIU rules, lack
of pts respect
and pts factors
reduced DT
effectiveness.
Findings:
RP, rather than
DT, are used in
response to EPB.

Decision for Use

Design:
Descriptive
Qualitative
Purpose: To
investigate PP on
staff, pts, and EI
on use and
effectiveness of
DT.

Major Variables &
Definitions
IV1: Staff
IV2: Pts
IV3: Environment
DT: verbal or nonverbal skills to
reduce A without
RP: Seclusion, PR,
PH, medication

r
University
of
Medical
Sciences
South Iran
Bias: None
Declared
Citation
Price et al.
(2017)
Patient
perspective
s on
barriers and
enablers to
the use and
effectivene
ss of deescalation
techniques
for the
manageme
nt of
violence
and
aggression
in mental
health
settings.

Semi structured,
inpatient
interviews;
digitally
recorded,
transcribed
verbatim by
SUR.

Framework
Analysis

LOE: 4
Conclusions: Results and
findings provide indicators
of OBC targets for
interventions seeking to
reduce violence and RP
through DT.
Strengths: detailed N,
thorough discussion of
themes and findings.
Weaknesses: Pts with only
EB, RP were included.
Sampling limited to PIU pts.
Only.
Feasibility:
Findings be utilized to
improve DT and improve
patient outcomes across all
settings and populations of
patients.

Key: A - adolescents, AG - agitation, AGG - aggression, AP - Agreement to participate, B - bachelor, B - boys, BI - behavioral indicators, BSN- bachelor degree in nursing, CCD - comprehensive
care delivery, CD - control and dominance, CE - coercive interventions, CD - communicative process, D- de-escalation, DI - duration of intervention, DQ- delinquent behavior, DT - de-escalation
techniques, E - environmental EB - escalating behavior, EBT - evidence based treatments, EI - Environmental Influences EL - education level, EPB - escalating patient behavior, EPN - years in
psychiatric nursing, ES - effect size, FAC - factors affecting connections, FCO - failure to communicate with others, FMHC - finnish mental health act, G - girl, SI - inpatient, ICS- insufficient
communication skills, IL - interview length, IMM - intramuscular injectable medication, IO - increased observation, IP - interpersonal process, ITP - individual treatment plans, LNP- large number of
pts, LOK - lack of knowledge, LSRC- lack of staff respect for culture, M - mean, Mdn - median, Mo - mode, MPS - manpower shortage, MSN - masters education in nursing, N - no, N - population
size, n - sample size, NA- negative attitude, NC - # of pts in control group, NI - # of pts in intervention group, NPB - nurse patient barriers, NPC - negative personal characteristics, NPR - nurse
patient relationship, NPR - nurse patient relationship, NRV - nurse related variables, OBC - organizational behavior change, OBP - organizational barriers to relationship between nurse and pts, ORV
- organizational variables, P - psychopathological, PH - physical hold, PIU - psychiatric inpatient unit, PMT - parent management training, PPB - patient perspective barriers, PPE - patient perspective
enablers, PR - physical restraint, PRB - patient related variables, PRNM - PRN medication, PRU - patterns of restraint use, Pts- patients, PV - physical violence, PW - psychiatric ward, R - restraint,
Ra -Range, RP - restrictive practices, RRI - restraint reduction initiatives, RU - restraint utilization, S - seclusion, SD - standard deviation, SUR - service user researcher , TF - time frame, TR therapeutic relationship, WE - work exhaustion, WO- work overload, Y - yes

AGGRESSION AND INTERVENTIONS
Citation

Theoretical
Framework

Sample/Setting

Design/ Purpose

Time out: N =
17 (65%)
IO: N = 17
(65%)
None: N = 2
(7%)
IL: 3 min-1
hr:50 min
IL M: 33 min
Demographics:
Setting: PIU
TF: 2014
Inclusion: PIU
admission
within 2014;
involvement in
EB with staff
intervention.
Informed
Consent;
English
speaking
Exclusion: Pts
without EB pr
RP
Attrition:
None
Sample/Setting

Country:
United
Kingdom
Funding:
The
National
Institute of
Health
Research,
Doctoral
Research
Fellowship
Program
Bias: None
Declared

Citation

Theoretical
Framework

28

Design/Purpose

Major Variables &
Definitions

Measurement

Analysis

Findings/
Theme

Decision for Use

Major Variables &
Definitions

Measurements

Analysis

Findings

Decision for Use

Key: A - adolescents, AG - agitation, AGG - aggression, AP - Agreement to participate, B - bachelor, B - boys, BI - behavioral indicators, BSN- bachelor degree in nursing, CCD - comprehensive
care delivery, CD - control and dominance, CE - coercive interventions, CD - communicative process, D- de-escalation, DI - duration of intervention, DQ- delinquent behavior, DT - de-escalation
techniques, E - environmental EB - escalating behavior, EBT - evidence based treatments, EI - Environmental Influences EL - education level, EPB - escalating patient behavior, EPN - years in
psychiatric nursing, ES - effect size, FAC - factors affecting connections, FCO - failure to communicate with others, FMHC - finnish mental health act, G - girl, SI - inpatient, ICS- insufficient
communication skills, IL - interview length, IMM - intramuscular injectable medication, IO - increased observation, IP - interpersonal process, ITP - individual treatment plans, LNP- large number of
pts, LOK - lack of knowledge, LSRC- lack of staff respect for culture, M - mean, Mdn - median, Mo - mode, MPS - manpower shortage, MSN - masters education in nursing, N - no, N - population
size, n - sample size, NA- negative attitude, NC - # of pts in control group, NI - # of pts in intervention group, NPB - nurse patient barriers, NPC - negative personal characteristics, NPR - nurse
patient relationship, NPR - nurse patient relationship, NRV - nurse related variables, OBC - organizational behavior change, OBP - organizational barriers to relationship between nurse and pts, ORV
- organizational variables, P - psychopathological, PH - physical hold, PIU - psychiatric inpatient unit, PMT - parent management training, PPB - patient perspective barriers, PPE - patient perspective
enablers, PR - physical restraint, PRB - patient related variables, PRNM - PRN medication, PRU - patterns of restraint use, Pts- patients, PV - physical violence, PW - psychiatric ward, R - restraint,
Ra -Range, RP - restrictive practices, RRI - restraint reduction initiatives, RU - restraint utilization, S - seclusion, SD - standard deviation, SUR - service user researcher , TF - time frame, TR therapeutic relationship, WE - work exhaustion, WO- work overload, Y - yes

AGGRESSION AND INTERVENTIONS
Citation
Putkonen et
al. (2013)
Clusterrandomized
controlled
trial of
reducing
seclusion
and
restraint in
secured
care of men
with
schizophre
nia
Country:
Finland
Funding:
National
Institutes of
Health and
Welfare
and Finnish
Ministry of
Health
Bias: None
Declared
Citation
ErcoleFricke et al.
(2016)

Theoretical
Framework
Inferred to
the
Cognitive
Behavioral
Model

Theoretical
Framework
Piaget’s
Theory of
Cognitive

29

Design/Purpose

Sample/Setting

Design:
Randomized
controlled trial
study
Purpose: To
study if RP could
be prevented in
schizophrenic
pts.

N: 88
n: 13 PIU
Setting: State
run secured
hospital on IPU
in Finland
Diagnosis:
Schizophrenia
Time: 6 months
Only males
N = 88
Mean Age:
40.2
Inclusion:
Schizophrenia
diagnosis,
highest risk for
violence, IPU
admission,
None

Design/ Purpose

Sample/Setting

Design:
Quantitative,
comparative,

N: 564
n:242 Preimplementation

Major Variables &
Definitions
IV1: Six Core
Strategies
DV1: S/R outcome

Major Variables &
Definitions
IV: CPS
DV1: Restraints
DV2: self-harm

Measurement
IRR: Monthly
incidence rate
rations.

Analysis
Poisson’s
Regression
Analysis

Findings/
Theme
DV1:S/R
reduced by 30%
to 15% for
intervention IPU
CI: = .86-.90,
p<.001
IRR = .88, 95%
while control
IPU was 25%19%
IRR = .97, CI
= .93-1.01, p
= .056.
The difference
between the
groups
was significant
(p=.001),
S/R: Time
decreased from
110 to 56 hours
per 100 days of
intervention
IRR = 1.09, CI:
= .94-1.25, p
= .24.

Measurements

Analysis

Findings

Collaborative
problem‐solvin
g (CPS) model.

Chi-Square
Analysis,

DV1
t(40)=1.58(p
= .122),

Decision for Use
LOE: 2
Strengths: First RTC study
completed on the reduction
of S and R use.
Weaknesses: Short duration
for the study, unknown what
DT impacted the study
outcomes that are already
practiced. Attrition and
exclusion were not
discussed.
Conclusions: S/R were
prevented with 6 core
strategies intervention. The
proportion of patient-days
with seclusion,
restraint, or room
observation declined from
30% to 15% for
intervention
wards
Feasibility: This study can
be used in both extreme PIU
settings as well as less
extreme circumstances for
improved patient outcomes
and less RP.
Decision for Use
LOE: 2
Strengths: Long length of
study

Key: A - adolescents, AG - agitation, AGG - aggression, AP - Agreement to participate, B - bachelor, B - boys, BI - behavioral indicators, BSN- bachelor degree in nursing, CCD - comprehensive
care delivery, CD - control and dominance, CE - coercive interventions, CD - communicative process, D- de-escalation, DI - duration of intervention, DQ- delinquent behavior, DT - de-escalation
techniques, E - environmental EB - escalating behavior, EBT - evidence based treatments, EI - Environmental Influences EL - education level, EPB - escalating patient behavior, EPN - years in
psychiatric nursing, ES - effect size, FAC - factors affecting connections, FCO - failure to communicate with others, FMHC - finnish mental health act, G - girl, SI - inpatient, ICS- insufficient
communication skills, IL - interview length, IMM - intramuscular injectable medication, IO - increased observation, IP - interpersonal process, ITP - individual treatment plans, LNP- large number of
pts, LOK - lack of knowledge, LSRC- lack of staff respect for culture, M - mean, Mdn - median, Mo - mode, MPS - manpower shortage, MSN - masters education in nursing, N - no, N - population
size, n - sample size, NA- negative attitude, NC - # of pts in control group, NI - # of pts in intervention group, NPB - nurse patient barriers, NPC - negative personal characteristics, NPR - nurse
patient relationship, NPR - nurse patient relationship, NRV - nurse related variables, OBC - organizational behavior change, OBP - organizational barriers to relationship between nurse and pts, ORV
- organizational variables, P - psychopathological, PH - physical hold, PIU - psychiatric inpatient unit, PMT - parent management training, PPB - patient perspective barriers, PPE - patient perspective
enablers, PR - physical restraint, PRB - patient related variables, PRNM - PRN medication, PRU - patterns of restraint use, Pts- patients, PV - physical violence, PW - psychiatric ward, R - restraint,
Ra -Range, RP - restrictive practices, RRI - restraint reduction initiatives, RU - restraint utilization, S - seclusion, SD - standard deviation, SUR - service user researcher , TF - time frame, TR therapeutic relationship, WE - work exhaustion, WO- work overload, Y - yes

AGGRESSION AND INTERVENTIONS
Citation
Effects of a
collaborati
ve
problemsolving
approach
on an
inpatient
adolescent
psychiatric
unit.
Country:
USA
Funding:
Private
Grants
from
UNICO
foundation
and Island
Outreach
Foundation
Bias:
None
Declared
Citation
Franco et
al. (2016)
Effect of a
mindfulnes
s training

Theoretical
Framework
Developmen
t

Theoretical
Framework
Inferred
Orem’s
Model of
Nursing

30

Design/Purpose

Sample/Setting

quasiexperimental
Purpose: To
evaluate the
effectiveness of
CPS on patient
behavior
outcomes of
adolescents with
mental health
conditions.

n: 322
Postimplementa
tion
Setting: PIU
Years: 20082012
Demographics:
Male:161
Female:375
Inclusion: Age
12-17, not
limited by
gender, age,
diagnosis,
physical
capabilities,
other than
inpatient
psychiatric care
Exclusion:
None
Attrition:
Not reported

Design/ Purpose

Sample/Setting

Design:
A randomized
controlled trial
Purpose: To
analyze the

N: 27
n: 14 CG
n: 13 EG
Setting:

Major Variables &
Definitions
DV3: Length of stay
DV 4: Security calls

Major Variables &
Definitions
IV1: EP
(FMT)
DV1: Aggression
DV2: Impulsivity

Measurement
Staff surveys
hospital
medical records

Measurements
1.The Barratt
Impulsivity
Scale (BIS)

Analysis
Independent
T tests

Analysis
Mann–
Whitney U

Cohen’s d

Findings/
Theme
DV2
self-inflicted
injury
t(131)=5.21 (p
= .001)
DV3 length of
stay t (98) =1.58
(p = .001),
DV4
T (98)=9.00
SD 3.29 (p
= .001)
Effect Size:
Large

Findings
DV1: Z=3.94;
p=0.005 d=1.16
(13.69)
DV2: Z=3.68;
p=0.008 (p <

Decision for Use
Weaknesses: Limited
demographics
Conclusions:
CPS was shown to be
effective in substantial
reduction of restraint.
Feasibility: The study
identified elements that can
be utilized across the
continuum of adolescent
care, not only in hospital but
also in school and
community environments.

Decision for Use
LOE: 2
Strengths: adolescent
focused, RTC
Weaknesses:
Small sample size

Key: A - adolescents, AG - agitation, AGG - aggression, AP - Agreement to participate, B - bachelor, B - boys, BI - behavioral indicators, BSN- bachelor degree in nursing, CCD - comprehensive
care delivery, CD - control and dominance, CE - coercive interventions, CD - communicative process, D- de-escalation, DI - duration of intervention, DQ- delinquent behavior, DT - de-escalation
techniques, E - environmental EB - escalating behavior, EBT - evidence based treatments, EI - Environmental Influences EL - education level, EPB - escalating patient behavior, EPN - years in
psychiatric nursing, ES - effect size, FAC - factors affecting connections, FCO - failure to communicate with others, FMHC - finnish mental health act, G - girl, SI - inpatient, ICS- insufficient
communication skills, IL - interview length, IMM - intramuscular injectable medication, IO - increased observation, IP - interpersonal process, ITP - individual treatment plans, LNP- large number of
pts, LOK - lack of knowledge, LSRC- lack of staff respect for culture, M - mean, Mdn - median, Mo - mode, MPS - manpower shortage, MSN - masters education in nursing, N - no, N - population
size, n - sample size, NA- negative attitude, NC - # of pts in control group, NI - # of pts in intervention group, NPB - nurse patient barriers, NPC - negative personal characteristics, NPR - nurse
patient relationship, NPR - nurse patient relationship, NRV - nurse related variables, OBC - organizational behavior change, OBP - organizational barriers to relationship between nurse and pts, ORV
- organizational variables, P - psychopathological, PH - physical hold, PIU - psychiatric inpatient unit, PMT - parent management training, PPB - patient perspective barriers, PPE - patient perspective
enablers, PR - physical restraint, PRB - patient related variables, PRNM - PRN medication, PRU - patterns of restraint use, Pts- patients, PV - physical violence, PW - psychiatric ward, R - restraint,
Ra -Range, RP - restrictive practices, RRI - restraint reduction initiatives, RU - restraint utilization, S - seclusion, SD - standard deviation, SUR - service user researcher , TF - time frame, TR therapeutic relationship, WE - work exhaustion, WO- work overload, Y - yes

AGGRESSION AND INTERVENTIONS
Citation

Theoretical
Framework

Program on
the
impulsivity
and
aggression
levels of
adolescents
with
behavioral
problems in
the
classroom.
Country:
Spain
Funding:
National
R+D Plan
of the
Ministry of
Economy
and
Finance
Bias: None
Declared

Citation

Theoretical
Framework

31

Design/Purpose

Sample/Setting

effects of a
mindfulness
training psychoeducative
program on
impulsivity and
aggression levels
in a sample of
high school
students.

A public high
school center
located in the
province of
Granada
Demographics:
59% of the
participants
were boys and
41% girls. The
control group
was made up of
14 individuals
(57% boys and
43% girls),
while the 13
individuals
remaining were
sent to the
experimental
group (62%
boys and 38%
girls).
Inclusion: In
school
Exclusion:
None
Attrition: None

Design/ Purpose

Sample/Setting

Major Variables &
Definitions
Fluir Meditation
Technique (FMT):
Mindfulness
intervention

Major Variables &
Definitions

Measurement

Analysis

Cronbach’s
alpha= 0.77 to
0.92.
2. Aggression
Questionnaire
(AQ)
Cronbach’s
alpha= 0.72 to
0.85.

Measurements

Findings/
Theme
0.01; d=0.679
(16.16%)
Cohen’s d: >1.5
Effect Size:
Moderate

Analysis

Findings

Decision for Use
Conclusions: Reduction of
impulsivity and aggression
noted with this study.
Feasibility: This study can
be used in multiple settings
for effectiveness reducing
S/R

Decision for Use

Key: A - adolescents, AG - agitation, AGG - aggression, AP - Agreement to participate, B - bachelor, B - boys, BI - behavioral indicators, BSN- bachelor degree in nursing, CCD - comprehensive
care delivery, CD - control and dominance, CE - coercive interventions, CD - communicative process, D- de-escalation, DI - duration of intervention, DQ- delinquent behavior, DT - de-escalation
techniques, E - environmental EB - escalating behavior, EBT - evidence based treatments, EI - Environmental Influences EL - education level, EPB - escalating patient behavior, EPN - years in
psychiatric nursing, ES - effect size, FAC - factors affecting connections, FCO - failure to communicate with others, FMHC - finnish mental health act, G - girl, SI - inpatient, ICS- insufficient
communication skills, IL - interview length, IMM - intramuscular injectable medication, IO - increased observation, IP - interpersonal process, ITP - individual treatment plans, LNP- large number of
pts, LOK - lack of knowledge, LSRC- lack of staff respect for culture, M - mean, Mdn - median, Mo - mode, MPS - manpower shortage, MSN - masters education in nursing, N - no, N - population
size, n - sample size, NA- negative attitude, NC - # of pts in control group, NI - # of pts in intervention group, NPB - nurse patient barriers, NPC - negative personal characteristics, NPR - nurse
patient relationship, NPR - nurse patient relationship, NRV - nurse related variables, OBC - organizational behavior change, OBP - organizational barriers to relationship between nurse and pts, ORV
- organizational variables, P - psychopathological, PH - physical hold, PIU - psychiatric inpatient unit, PMT - parent management training, PPB - patient perspective barriers, PPE - patient perspective
enablers, PR - physical restraint, PRB - patient related variables, PRNM - PRN medication, PRU - patterns of restraint use, Pts- patients, PV - physical violence, PW - psychiatric ward, R - restraint,
Ra -Range, RP - restrictive practices, RRI - restraint reduction initiatives, RU - restraint utilization, S - seclusion, SD - standard deviation, SUR - service user researcher , TF - time frame, TR therapeutic relationship, WE - work exhaustion, WO- work overload, Y - yes

AGGRESSION AND INTERVENTIONS
Citation
Makki, et
al., (2018).
Implement
ation of an
ACT
curriculum
on an
adolescent
inpatient
Psychiatric
Unit: A
Quality
Improveme
nt Project.
Country:
USA
Funding:
Patient
Centered
Outcomes
Research
Institute
and HRSA.
Health
Resources
and
Bias: None
Citation

Theoretical
Framework
The Neuman
systems
model

Theoretical
Framework

32

Design/Purpose

Sample/Setting

Design: Quality
Improvement
Study
Naturalistic
Study
Purpose: The
measure changes
in parent/patient
knowledge and
satisfaction with
group
programming
and changes on
the Avoidance
and Fusion
Questionnaire
for Youth (AFQY);

N = 184
Male=29
Female= 68
Age M = 15.47
Length of Stay
M= 9.2
Setting: PIU

Design/ Purpose

Sample/Setting

Major Variables &
Definitions
IV: ACT
DV1: behavior

Major Variables &
Definitions

Measurement

Analysis

The Avoidance
and Fusion
Questionnaire
for Youth
(AFQ-Y)
AFQ-Y8
demonstrated
good internal
consistency
with
Cronbach’s
alpha ranging
from .90 to .93
ACT=Acceptan
ce and
Commitment
Therapy:

SPSS
Paired sample
T-test

Measurements

Analysis

Findings/
Theme
D1: 2.51 (4.4)
T = 6.054, DF
183, P < .001).

Findings

Decision for Use
LOE: 3
Strengths: provided
evidence-based practice
results
Weaknesses: Small Sample
Size
Conclusions:
The project demonstrates
that it is possible to
implement an evidencebased intervention and
create a positive impact
during brief inpatient
treatment. There was an
interaction effect between
the amount of
programming and
improvement
Feasibility:
This project demonstrated
that it is feasible to
implement evidence-based
programming on a shortterm adolescent psychiatric
unit

Decision for Use

Key: A - adolescents, AG - agitation, AGG - aggression, AP - Agreement to participate, B - bachelor, B - boys, BI - behavioral indicators, BSN- bachelor degree in nursing, CCD - comprehensive
care delivery, CD - control and dominance, CE - coercive interventions, CD - communicative process, D- de-escalation, DI - duration of intervention, DQ- delinquent behavior, DT - de-escalation
techniques, E - environmental EB - escalating behavior, EBT - evidence based treatments, EI - Environmental Influences EL - education level, EPB - escalating patient behavior, EPN - years in
psychiatric nursing, ES - effect size, FAC - factors affecting connections, FCO - failure to communicate with others, FMHC - finnish mental health act, G - girl, SI - inpatient, ICS- insufficient
communication skills, IL - interview length, IMM - intramuscular injectable medication, IO - increased observation, IP - interpersonal process, ITP - individual treatment plans, LNP- large number of
pts, LOK - lack of knowledge, LSRC- lack of staff respect for culture, M - mean, Mdn - median, Mo - mode, MPS - manpower shortage, MSN - masters education in nursing, N - no, N - population
size, n - sample size, NA- negative attitude, NC - # of pts in control group, NI - # of pts in intervention group, NPB - nurse patient barriers, NPC - negative personal characteristics, NPR - nurse
patient relationship, NPR - nurse patient relationship, NRV - nurse related variables, OBC - organizational behavior change, OBP - organizational barriers to relationship between nurse and pts, ORV
- organizational variables, P - psychopathological, PH - physical hold, PIU - psychiatric inpatient unit, PMT - parent management training, PPB - patient perspective barriers, PPE - patient perspective
enablers, PR - physical restraint, PRB - patient related variables, PRNM - PRN medication, PRU - patterns of restraint use, Pts- patients, PV - physical violence, PW - psychiatric ward, R - restraint,
Ra -Range, RP - restrictive practices, RRI - restraint reduction initiatives, RU - restraint utilization, S - seclusion, SD - standard deviation, SUR - service user researcher , TF - time frame, TR therapeutic relationship, WE - work exhaustion, WO- work overload, Y - yes

AGGRESSION AND INTERVENTIONS
Citation
Singh et
al., (2016)
Effectivene
ss of
caregiver
training in
mindfulnes
s-based
positive
behavior
support
(MBPBS)
vs.
training-asUsual
(TAU): A
randomized
controlled
trial.
Country:
USA
Funding:
None
Bias: 1
author is
the
developer
of the
MBPBS
program.

Theoretical
Framework
Inferred
Interpersona
l Theory

33

Design/Purpose

Sample/Setting

Design:
A randomized
controlled trial
(RCT)
Purpose: The
study was to
evaluate in a
randomized
controlled trial
(RCT) the
comparative
effectiveness of
MindfulnessBased Positive
Behavior
Support
(MBPBS) and
Training-asUsual (TAU) for
caregivers in a
congregate care
facility for
individuals with
severe and
profound IDD.

N: 77
Caregivers
N:48 patients
Setting: large
congregate care
facility for
individuals with
physical
aggression,
property
destruction,
pica,
rumination,
stereotypy.
Inclusion:
full-time
employment,
consent to
participate in
the training, and
availability
during the
training
Exclusion: Not
meeting
inclusion
Attrition: 30

Major Variables &
Definitions
IV1: CG Training
IV2:
DV1: Aggressive
Events
DV2: Physical
restraints
Stat medicine
One-to-one staffing
Staff stress
Staff turnover
Cost effectiveness
data

Measurement
(MBPBS)
MindfulnessBased Positive
Behavior
Support
(TAU)
Training-AsUsual
The TAU
trainer

Analysis
Chi-Square
and
Independent
Samples t-test
(all p’s >
0.05)

Findings/
Theme
Findings: MBPBS training
(M 14.00, SD
3.31) to the 40weeks during
post- MBPBS
training (M 2.00,
SD 2.53), t (39) –
18.20, p < 0.001
(Cohen’s d 5.83).
Weekly injuries
to staff decreased
-MBPBS
training (M 3.00,
SD 2.61) and
post-MBPBS
training (M 1.00,
SD 1.06), t (39) –
7.44, p < 0.001
(Cohen’s d 2.38).
In addition, the
change in weekly
peer injuries
from preMBPBS training
(M 5.00, SD
3.14) to postMBPBS training
(M 1.00, SD
1.39) was
statistically
significant, t (39)

Decision for Use
LOE: 2
Weaknesses:
Unknown equivalence of
the training in each of the
two conditions; need to be
assessed in different care
settings, such as institutions,
group homes, family homes,
and within the larger
community settings.
Strengths: the cost
effectiveness; large sample.
Conclusions:
MBPBS may provide an
effective means of
enhancing socially
acceptable bidirectional
engagement of caregivers
and care recipients within a
person-centered context.
Feasibility: MBPBS may
be a viable approach to
nurse training to improve
the psychological wellbeing of both nurses and the
care recipients.

Key: A - adolescents, AG - agitation, AGG - aggression, AP - Agreement to participate, B - bachelor, B - boys, BI - behavioral indicators, BSN- bachelor degree in nursing, CCD - comprehensive
care delivery, CD - control and dominance, CE - coercive interventions, CD - communicative process, D- de-escalation, DI - duration of intervention, DQ- delinquent behavior, DT - de-escalation
techniques, E - environmental EB - escalating behavior, EBT - evidence based treatments, EI - Environmental Influences EL - education level, EPB - escalating patient behavior, EPN - years in
psychiatric nursing, ES - effect size, FAC - factors affecting connections, FCO - failure to communicate with others, FMHC - finnish mental health act, G - girl, SI - inpatient, ICS- insufficient
communication skills, IL - interview length, IMM - intramuscular injectable medication, IO - increased observation, IP - interpersonal process, ITP - individual treatment plans, LNP- large number of
pts, LOK - lack of knowledge, LSRC- lack of staff respect for culture, M - mean, Mdn - median, Mo - mode, MPS - manpower shortage, MSN - masters education in nursing, N - no, N - population
size, n - sample size, NA- negative attitude, NC - # of pts in control group, NI - # of pts in intervention group, NPB - nurse patient barriers, NPC - negative personal characteristics, NPR - nurse
patient relationship, NPR - nurse patient relationship, NRV - nurse related variables, OBC - organizational behavior change, OBP - organizational barriers to relationship between nurse and pts, ORV
- organizational variables, P - psychopathological, PH - physical hold, PIU - psychiatric inpatient unit, PMT - parent management training, PPB - patient perspective barriers, PPE - patient perspective
enablers, PR - physical restraint, PRB - patient related variables, PRNM - PRN medication, PRU - patterns of restraint use, Pts- patients, PV - physical violence, PW - psychiatric ward, R - restraint,
Ra -Range, RP - restrictive practices, RRI - restraint reduction initiatives, RU - restraint utilization, S - seclusion, SD - standard deviation, SUR - service user researcher , TF - time frame, TR therapeutic relationship, WE - work exhaustion, WO- work overload, Y - yes

AGGRESSION AND INTERVENTIONS

34

Citation

Theoretical
Framework

Design/Purpose

Sample/Setting

Major Variables &
Definitions

Measurement

Analysis

Citation

Theoretical
Framework

Design/ Purpose

Sample/Setting

Major Variables &
Definitions

Measurements

Analysis

Testad et
al. (2015).
Modeling
and
evaluating
evidencebased
continuing
education
program in
nursing
home
dementia
care
(MEDCED
)-training
of care
home staff
to reduce
use of
restraint in
care home
residents
with
dementia.
A cluster
randomized

Person
Centered
Care Theory

Design: NRTC
Purpose: To
evaluate the
effectiveness of a
tailored 7‐month
training
intervention
“Trust Before
Restraint,” in
reducing use of
restraint.

N: 274
n: 118 IG
n: 156 CG
Inclusion:
Inpatient
Dementia Unit
Exclusion:
None
Attrition: 72
Setting:
Nursing home
dementia unit

IV1:
TFT Interventions
DV1: Any restraint
or coercive measure
DV2: Agitation

TFT
NPI
CMAI
CohenMansfield
Agitation
Inventory:
CMAI;
NPI:
Neuropsychiatri
c Inventory;
Trust Before
Restraint TFT

Independent
T test
Paired sample
t test

Findings/
Theme
–7.67, p < 0.001
(Cohen’s d 2.46).
Findings

Decision for Use

DV1:
2.48 (0.051);
6.99; p=0.051;
(p<0.001)
DV2: 0.9
(0.228); 1.3
(0.388); p-value=
0.702

LOE: 2
Strengths: Large study,
RTC
Weaknesses: Large attrition
rate
Conclusions: Significant
reduction in use of restraint
in both intervention and
control groups.
Feasibility: This could be
implemented in different
settings with different
patients such as psychiatric
units.

Decision for Use

Key: A - adolescents, AG - agitation, AGG - aggression, AP - Agreement to participate, B - bachelor, B - boys, BI - behavioral indicators, BSN- bachelor degree in nursing, CCD - comprehensive
care delivery, CD - control and dominance, CE - coercive interventions, CD - communicative process, D- de-escalation, DI - duration of intervention, DQ- delinquent behavior, DT - de-escalation
techniques, E - environmental EB - escalating behavior, EBT - evidence based treatments, EI - Environmental Influences EL - education level, EPB - escalating patient behavior, EPN - years in
psychiatric nursing, ES - effect size, FAC - factors affecting connections, FCO - failure to communicate with others, FMHC - finnish mental health act, G - girl, SI - inpatient, ICS- insufficient
communication skills, IL - interview length, IMM - intramuscular injectable medication, IO - increased observation, IP - interpersonal process, ITP - individual treatment plans, LNP- large number of
pts, LOK - lack of knowledge, LSRC- lack of staff respect for culture, M - mean, Mdn - median, Mo - mode, MPS - manpower shortage, MSN - masters education in nursing, N - no, N - population
size, n - sample size, NA- negative attitude, NC - # of pts in control group, NI - # of pts in intervention group, NPB - nurse patient barriers, NPC - negative personal characteristics, NPR - nurse
patient relationship, NPR - nurse patient relationship, NRV - nurse related variables, OBC - organizational behavior change, OBP - organizational barriers to relationship between nurse and pts, ORV
- organizational variables, P - psychopathological, PH - physical hold, PIU - psychiatric inpatient unit, PMT - parent management training, PPB - patient perspective barriers, PPE - patient perspective
enablers, PR - physical restraint, PRB - patient related variables, PRNM - PRN medication, PRU - patterns of restraint use, Pts- patients, PV - physical violence, PW - psychiatric ward, R - restraint,
Ra -Range, RP - restrictive practices, RRI - restraint reduction initiatives, RU - restraint utilization, S - seclusion, SD - standard deviation, SUR - service user researcher , TF - time frame, TR therapeutic relationship, WE - work exhaustion, WO- work overload, Y - yes

AGGRESSION AND INTERVENTIONS
Citation

Theoretical
Framework

Design/Purpose

35
Sample/Setting

Major Variables &
Definitions

Measurement

Analysis

Findings/
Theme

Decision for Use

controlled
trial.
Country:
Norway
Funding:
Norwegian
Research
Counsel
Bias: None
Declared

Key: A - adolescents, AG - agitation, AGG - aggression, AP - Agreement to participate, B - bachelor, B - boys, BI - behavioral indicators, BSN- bachelor degree in nursing, CCD - comprehensive
care delivery, CD - control and dominance, CE - coercive interventions, CD - communicative process, D- de-escalation, DI - duration of intervention, DQ- delinquent behavior, DT - de-escalation
techniques, E - environmental EB - escalating behavior, EBT - evidence based treatments, EI - Environmental Influences EL - education level, EPB - escalating patient behavior, EPN - years in
psychiatric nursing, ES - effect size, FAC - factors affecting connections, FCO - failure to communicate with others, FMHC - finnish mental health act, G - girl, SI - inpatient, ICS- insufficient
communication skills, IL - interview length, IMM - intramuscular injectable medication, IO - increased observation, IP - interpersonal process, ITP - individual treatment plans, LNP- large number of
pts, LOK - lack of knowledge, LSRC- lack of staff respect for culture, M - mean, Mdn - median, Mo - mode, MPS - manpower shortage, MSN - masters education in nursing, N - no, N - population
size, n - sample size, NA- negative attitude, NC - # of pts in control group, NI - # of pts in intervention group, NPB - nurse patient barriers, NPC - negative personal characteristics, NPR - nurse
patient relationship, NPR - nurse patient relationship, NRV - nurse related variables, OBC - organizational behavior change, OBP - organizational barriers to relationship between nurse and pts, ORV
- organizational variables, P - psychopathological, PH - physical hold, PIU - psychiatric inpatient unit, PMT - parent management training, PPB - patient perspective barriers, PPE - patient perspective
enablers, PR - physical restraint, PRB - patient related variables, PRNM - PRN medication, PRU - patterns of restraint use, Pts- patients, PV - physical violence, PW - psychiatric ward, R - restraint,
Ra -Range, RP - restrictive practices, RRI - restraint reduction initiatives, RU - restraint utilization, S - seclusion, SD - standard deviation, SUR - service user researcher , TF - time frame, TR therapeutic relationship, WE - work exhaustion, WO- work overload, Y - yes

Running head: AGGRESSION AND INTERVENTIONS

36
Appendix B

Table 2
Synthesis Table
Author

Blair et al.

Bowers et al.

Year

2016
PS/3

2015
RTC/2

Design/LOE

Ercole-Fricke
et al.
2016
QT/2

Franco et al.

Makki et al.

Pazargadi et al.

Price et al.

Putkonen et al.

Singh et al.

Testad et al.

2016
RTC/2

2018
QI/3

2015
DQ/4

2017
DQ/4

2013
RTC/2

2016
RTC/2

2015
RTC/2

1
14
1 year
38.5
50%
50%
PIU
SSI

7
26
6 months
NG
69%
31%
PIU
SSI

13
88
6 months
40.2
n/a
88
PIU
IRR

1
18

24
274
7 months
88.2
72.9%

Study
Characteristics
Demographics
Number of Sites
N
Time
Mean Age
Female %
Male %
Setting
Measurement Tool
Used

1
3884
3 years
49.7%
50.3%
PIU
BVC

15
564
24 weeks
33
59.4%
NG
PIU
APDQ
SHAS

1
5 years
14.5
375
161
PIU
CPS

1
27
10 weeks
15.85
41%
59%
HS
BIS-11
AQ

184
9.2
15.47
29
29
PIU
AFQ-Y
ACT

26

CGH
MBPBS
TAU

NH
TBR

Interventions
ACT

x

MBPBS

x
x

x
x

AQ
CPS

x

6 Core Strategies

x

SSI

x

BIS
BVC
Structured
Education/Training
SNPCC

x

x
x
x

x

x

x

x

x

x
Findings/Outcome

Agitation

↓

↓

Key: ACT - acceptance and commitment therapy; AFQ- Y - avoidance and fusion questionnaire for youth; AQ - aggression questionnaire; BIS - barratt impulsivity scale; BVC - broset violence
checklist; CPS - collaborative problem solving; DQ - descriptive qualitative; GH - group home; HS - high school; IRR - inter rater reliability; MBPBS - mindfulness-based positive behavior support;
NG - not given; NH - nursing home; PIU - psychiatric inpatient unit; PS - pilot study; QI - quality improvement ; QT - quantitative study; RTC - randomized control study; SMPCC - safewards
model patient-staff conflict checklist; SSI - semi-structured interviews; TAU - treatment as usual; TBR - trust before restraint; ↓ decreased;↑ increased; ≠ not statistically significant

AGGRESSION AND INTERVENTIONS

37

Impulsivity
Restraint

↓
↓

↓

↓

↓

Seclusion
Adverse Event

↓

↓

↓

↓
↓

↓

↓

↓

Verbal Aggression

↓

Physical
Aggression
Staff Injuries

↓

↓
↓

↓

↓

Staff Turnover

↓

↓

Staff Stress

↓

↓

Key: ACT - acceptance and commitment therapy; AFQ- Y - avoidance and fusion questionnaire for youth; AQ - aggression questionnaire; BIS - barratt impulsivity scale; BVC - broset violence
checklist; CPS - collaborative problem solving; DQ - descriptive qualitative; GH - group home; HS - high school; IRR - inter rater reliability; MBPBS - mindfulness-based positive behavior support;
NG - not given; NH - nursing home; PIU - psychiatric inpatient unit; PS - pilot study; QI - quality improvement ; QT - quantitative study; RTC - randomized control study; SMPCC - safewards
model patient-staff conflict checklist; SSI - semi-structured interviews; TAU - treatment as usual; TBR - trust before restraint; ↓ decreased;↑ increased; ≠ not statistically significant

Running head: AGGRESSION AND INTERVENTIONS
Appendix C
Figure 1
Theory of Planned Behavior

38

AGGRESSION AND INTERVENTIONS

39
Appendix D

Figure 2
The Precede-Proceed Model

Figure 3

AGGRESSION AND INTERVENTIONS
Budget
Project
Phase

Activities

40

Direct
Cost

Indirect
Cost

Funding

Preparation Design and print
pretest materials
for participating
staff (20 pretests
printed)

$50

$0 None

Create
educational
intervention
power point
presentation
(Print 20
handouts)
Design and print
posttest
evaluation
materials (20
posttests printed)

$50

$0 None

$50

$0 None

1 Room for
training
presentation
(hospital campus)

$0

$0 None

Utilities:
Lighting, air,
internet,
computer use,
storage.
Materials: Pens,
folders
Equipment:
Locked desk
drawer for testing
information
storage for patient
privacy.
Materials
and Supplies:

$20

$0 None

Delivery

Subtotal

$150

Total
Cost

Potential
Revenue/Cost
Savings

AGGRESSION AND INTERVENTIONS
Project
Activities
Direct
Phase
Cost

41
Indirect
Cost

Funding

RN Time: 1 hour
($35.00) p/hr.
(35x10 RN)

$0

$350 None

BHT Time: 1
hour @ $15 p/hr.
(15x10 BHT)

$0

$150 None

Review and
analysis of results
(SPSS)

$0

Restraint
Monthly Cost
to facility

Monthly restraint
Average: 15

(See details
cost below)

Average Length:
2 Hours

PRN Meds
$1455
Call to DR
$2475

Evaluation

Subtotal

Reduced
seclusion/restraint
use on the
adolescent units,
reduced staff and
patient injuries

Potential
Revenue/Cost
Savings

$500
$0 None
Total:
$650
RN
Time
$1050
BHT
Time:
$900

None

$5880
Project
Results &
Benefit

Total
Cost

Reduce
cost of
staff time
lost, PRN
medication,
and related
supplies

Less
staff and
patient
injuries,
less sick
calls,
less turn
over,
more
retention

Reduced
Banner
costs, gross
profit
increase as
result.

Project
Cost Savings:
$5230
Reduction in
healthcare
waste, better
patient
outcomes,
quality health
care, and cost
reduction.

Budget Justification
** Other Costs: Travel (Clinical site is 80 miles distance from my home round trip), SPSS (Included in
ASU tuition), cost of staff recruitment, laptop/power point software and training content for nurses and BHT’s
in the hospital will be incurred by the student. Student is trained in house expert for restraint reduction reeducation.
Seclusion and Restrain Episode Cost Breakdown:
Average Pay Per Hour:
 Banner RN $35
 Banner Behavioral Health Tech $15
Average Monthly Seclusion and Restraint Number: 15

AGGRESSION AND INTERVENTIONS
Average Banner Adolescent Seclusion/ Restraint Time from Start to Finish:
 2 hours

42

Average BHT Staff Present for 1 Restraint Episode:
 4 BHT’s
Average RN Staff Present for 1 Restraint Episode:
 2 RN’s
Includes:


Pre-Restraint:
o
o
o
o



Physical Hold/Restraint Application:
o
o
o
o



Therapeutic communication and de-escalation attempt by staff
Physical escort to seclusion room by staff
RN to Call MD for Seclusion/Restraint/ PRN medication orders
Obtain guardian consent for medication

Apply 4-point restraint to each limb
Administer PRN medication
Continuously monitor patient until contract for safety
Complete face to face assessment and restraint safety assessment

Post Restraint Activities:
o Documentation
o Notify adolescent patient’s legal guardian to inform of event
o RN complete incident report
o RN manager to notify insurance company if required.



PRN Medication Cost: “B52” -Benadryl 50mg/ml, Haldol 5mg/ml and Ativan 2mg/ml combination
injection.
o The average cost for haloperidol injectable solution (5 mg/mL) is around $17 for a supply of 25
milliliters.
o The cost for diphenhydramine injectable solution (50 mg/mL) is AROUND $22 for a supply of
10 milliliters.
o The cost for Ativan injectable solution (2 mg/mL) is around $58 for a supply of 25 milliliters.



Injection Supplies: Injection supplies include gloves, needle, syringe, alcohol wipe, band aid (total cost
unknown)



On Call Doctor: $165.00 per call after 5pm
Other Costs (Exact cost unknown):
Cost of Patient Injuries and medical expenses
Cost of Staff Injuries:
 Results in Time off from work, medical expenses, disability claims, and staff
turnover/replacement cost.

AGGRESSION AND INTERVENTIONS

43

Running head: AGGRESSION AND INTERVENTIONS

44

Figure 3. Logic Model for Seclusion and Restraint Reduction
Goals: To train and educate staff to reduce inpatient aggression and seclusion and restraint use.

INPUTS

OUTPUTS

Short
Short

A
Activities
BBHH Stakeholder
and Staff Support
ASU Mentor
Site Champion
Seclusion and
restraint curricula
Staff Time and Effort
Room location for
training.
Resources to
disseminate the
information.

Target Population
Activities
Staff Training on
de-escalation
Target Population
techniques

IMPACTS

OUTCOMES

Medium
Medium

Long

Long

Improved
communicat
ion and deescalation
skills

Reduction in
patient
aggression

Improved staff
–patient
relationships

Reduction in
staff and patient
injuries

Participation

Educate staff on
dangers associated
with seclusion and
restraints

Increase staff
knowledge to
reduce
seclusion and
restraint use

Improved
awareness of
dangers

Changes in staff
attitudes and
behaviors

Reduction/
Elimination of
seclusion and
restraint use

Pre and Post
knowledge tests

Reduction
in
healthcare
costs for
hospital,
staff and
patients
Improved
unit/
organizatio
n safety for
staff and
patients
Policy
changes

Improve and
strengthen deescalation
knowledge and
skills

Effective
communication
to reduce
adverse events

Improvement in
de-escalation
techniques to
reduce
aggression

Increased staff
confidence

Assumptions:
Staff de-escalation training will reduce the use of seclusion and restraints.
Staff education will reduce the use of seclusion and restraints.
Staff training and education will improve communication to reduce patient aggression that results in seclusion and restraint use.

Improved
patient
outcomes

AGGRESSION AND INTERVENTIONS

45