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Aggression on psychiatric wards develops under influence of patient, staff and ward factors. Assessment of naturalistic derived staff and ward factors might increase better understanding of how aggressive incidents develop on psychiatric wards. OBJECTIVE: Studying staff and ward factors including interactions between patients and nurses prior and after development of aggression, within a naturalistic closed ward setting. DESIGN: A prospective naturalistic experience sampling method (ESM) study. SETTING AND PARTICIPANTS: A high intensive care unit of a mental health institution in The Netherlands where 29 nurses answered beeps generated by an app during approximately 7 consecutive days with questions regarding their subjective feelings, ward atmosphere, location, interaction they had with patients and their colleagues and whether an incident took place. MAIN OUTCOME MEASURES: Associations were established between different staff and ward factors and the occurrence of aggressive incidents on the ward. RESULTS: Risk for aggression was associated with the nurse being with a patient (OR=2.26, 95% CI 0.99 to 5.15, p=0.05). No significant association was found between discussing with the patient and setting a limit or physical absence of the nurse on the one hand and aggression on the other. More experienced nurses encountered more aggression (OR=3.5, 95% CI 1.32 to 8.26, p=0.01). Age and gender of the nurse were not associated with aggression development. Exceeding the maximum bed capacity was associated with a greater risk for aggression (OR=5.36, 95% CI 1.69 to 16.99, p=0.004). There was no significant association when analysing a more positive atmosphere on the ward or positive affect of the nurse, but negative affect of the nurses showed a trend for an association with less aggression. CONCLUSION: Aggression is a problem that should be managed from a multidimensional perspective. The quality of interaction between nurses and patients is crucial. Exceeding the maximum bed capacity is likely associated with more aggression.

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INTRODUCTION: On psychiatric wards, aggressive behaviour displayed by patients is common and problematic. Understanding factors associated with the development of aggression offers possibilities for prevention and targeted interventions. This review discusses factors that contribute to the development of aggression on psychiatric wards. METHOD: In Pubmed and Embase, a search was performed aimed at: prevalence data, ward characteristics, patient and staff factors that are associated with aggressive behaviour and from this search 146 studies were included. RESULTS: The prevalence of aggressive behaviour on psychiatric wards varied (8-76%). Explanatory factors of aggressive behaviour were subdivided into patient, staff and ward factors. Patient risk factors were diagnosis of psychotic disorder or bipolar disorder, substance abuse, a history of aggression, younger age. Staff risk factors included male gender, unqualified or temporary staff, job strain, dissatisfaction with the job or management, burn-out and quality of the interaction between patients and staff. Staff protective factors were a good functioning team, good leadership and being involved in treatment decisions. Significant ward risk factors were a higher bed occupancy, busy places on the ward, walking rounds, an unsafe environment, a restrictive environment, lack of structure in the day, smoking and lack of privacy. CONCLUSION: Despite a lack of prospective quantitative data, results did show that aggression arises from a combination of patient factors, staff factors and ward factors. Patient factors were studied most often, however, besides treatment, offering the least possibilities in prevention of aggression development. Future studies should focus more on the earlier stages of aggression such as agitation and on factors that are better suited for preventing aggression such as ward and staff factors. Management and clinicians could adapt staffing and ward in line with these results.

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Background: Existing study quality and risk of bias lists for observational studies have important disadvantages. For this reason, a comprehensive widely applicable quality assessment tool for observational studies was developed. Methods: Criteria from three quality lists were merged into a new quality assessment tool: the observational study quality evaluation (OSQE). OSQE consists of a cohort, case-control, and cross-sectional version. Results: The OSQE cohort, the OSQE case-control, and the OSQE cross-sectional version include all items applicable to that type of study, for example, the representativeness of the study population, the validity of the independent and dependent variables, and the statistical methods used. Before scoring the OSQE, the rater is asked to define how to score items, in detail. A study can obtain a star for each item. Each item also has a veto cell. This cell can be checked when poor quality with respect to that specific item results in a low quality of the study despite stars on other items. Although stars add to a sum score, the comment field is the most important part of the OSQE. Conclusion: The OSQE presented in the current article provides a short, comprehensive, and widely applicable list to assess study quality and therewith risk of bias.

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INTRODUCTION: Non-pharmacological interventions preferably precede pharmacological interventions in acute agitation. Reviews of pharmacological interventions remain descriptive or compare only one compound with several other compounds. The goal of this study is to compute a systematic review and meta-analysis of the effect on restoring calmness after a pharmacological intervention, so a more precise recommendation is possible. METHOD: A search in Pubmed and Embase was done to isolate RCT's considering pharmacological interventions in acute agitation. The outcome is reaching calmness within maximum of 2 h, assessed by the psychometric scales of PANSS-EC, CGI or ACES. Also the percentages of adverse effects was assessed. RESULTS: Fifty-three papers were included for a systematic review and meta-analysis. Most frequent studied drug is olanzapine. Changes on PANNS-EC and ACES at 2 h showed the strongest changes for haloperidol plus promethazine, risperidon, olanzapine, droperidol and aripiprazole. However, incomplete data showed that the effect of risperidon is overestimated. Adverse effects are most prominent for haloperidol and haloperidol plus lorazepam. CONCLUSION: Olanzapine, haloperidol plus promethazine or droperidol are most effective and safe for use as rapid tranquilisation. Midazolam sedates most quickly. But due to increased saturation problems, midazolam is restricted to use within an emergency department of a general hospital.

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