Service users’ experiences and views of aggressive situations in mental health care: a systematic review and thematic synthesis of qualitative studies

Figures & data

Figure 1 Search and selection strategy.

Table 1 Quality assessment of included studies

Qualitative studies	CASP qualitative quality criteria meta
	A	B	C	D	E	F	G	H	I	J
Bensley et al (1995)^Citation27	✓	✘	✘	✓	✘	✓	✘	✘	✓	✓
Benson et al (2003)^Citation28	✓	✓	✓	✘	✓	✘	✓	✓	✓	✓
Bonner et al (2002)^Citation29	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓
Carlsson et al (2006)^Citation34	✓	✓	✓	✘	✓	✘	✓	✓	✓	✓
Hinsby and Baker (2004)^Citation7	✓	✓	✓	✘	✓	✘	✓	✓	✓	✓
Johnson et al (1997)^Citation31	✓	✓	✓	✘	✓	✓	✘	✓	✓	✓
Johnson and Delaney (2007)^Citation32	✓	✓	✓	✓	✓	✓	✓	✘	✓	✓
Kumar et al (2001)^Citation8	✓	✓	✓	✓	✓	✘	✓	✓	✓	✓
Meehan et al (2006)^Citation9	✓	✓	✓	✓	✓	✓	✓	✓	✓	✓
Quirk et al (2004)^Citation26	✓	✓	✓	✓	✓	✓	✘	✘	✓	✓
Mixed method studies	MMAT quality criteria metb
	1			2			3			4
Duxbury and whittington (2005)^Citation6	✓			✓			✓			✓
Ilkiw-Lavalle and Grenyer (2003)^Citation30	✓			✓			✓			✓
Omerov et al (2004)^Citation33	✓			✓			✓			✘

Notes: Symbols: ✓, yes; ✘, no/cannot tell.

a CASP qualitative studies: A: aims clearly stated; B: appropriate methodology; C: appropriate design to address the aims of the research; D: appropriate recruitment strategy; E: data collected in a way that addressed the research issue; F: adequate consideration of relationship between researcher and participants; G: consideration of ethical issues; H: sufficiently rigorousness in data analysis; I: findings clearly stated; J: consideration of relevance and transferability of the research;

b MMAT (mixed method studies): 1: relevant design; 2: relevant integration of data; 3: appropriate considerations; 4: appropriate criteria for qualitative/quantitative components.

Abbreviations: CASP, Critical Appraisal Skills Programme; MMAT, Mixed Methods Appraisal Tool.

Table 2 Characteristics of studies and themes identified in thematic analysis of service users’ experiences and views of aggressive situations, listed alphabetically

Author (year)	Study focus/aim	User participants and study location	Data collection and data analysis related to user experiences	Key findings reported by author	Codes identified by reviewer
Bensley et al (1995)^Citation27	To identify areas causing friction between patients and staff	69 patients, eight wards on two different state psychiatric hospitals, USA. Sex represented approximately equally, age from young adult to geriatric population	Qualitative interviews with patients Counts of number of wards on which each major topic had been discussed	Main issues believed to contribute to assault: smoking policies and access to outdoors, lack of respect from staff, excessive use of seclusion, and not enough explanation of rules	Contributory conditions: rigid and hierarchical ward structure; lack of respect and dialogue
Benson et al (2003)^Citation28	To examine how all involved (n=3) understood and attributed meaning to violent or aggressive situations and how these attributions justified individual perceptions, reactions, and actions	One female patient involved in two incidents, acute mental health inpatient unit, UK	Qualitative, semi-structured interviews. Discourse analytic techniques	Client and staff discourses were strikingly similar, and their most central concern was the attribution of blame	Contributory conditions: reactivation of earlier negative experiences; lack of care and respect from staff; ignored
Bonner et al (2002)^Citation29	To investigate factors found helpful and unhelpful, during and in the aftermath of manual physical restraint. And to investigate what had happened and any precipitants in the recent incident	Six mental health patients involved in six incidents, UK	Qualitative, semi-structured interviews. Analyzed by the technique of Miles and Huberman	The patients valued staff time and attention but felt that they received too little attention. They reported feeling upset, distressed, and ignored prior to the incidents and isolated and ashamed afterward. Post-incident debriefing was valued, but rare	Contributory conditions: mental symptoms; unpredictable and hostile milieu; rigid ward structure; not understood, misinterpreted, and ignored by staff Preventive conditions: sensitive, attentive, and caring staff; debriefing of incidents; response on early warning signals
Carlsson et al (2006)^Citation34	Aims to describe the essence of violent encounters, as experienced by patients	Nine patients from psychiatric hospital ward (n=4) and forensic hospital (n=5), Sweden	Qualitatively guided by phenomenological method. Analyzed within a reflective lifeworld approach	Explicate violent encounters characterized by a tension between “authentic personal”and “detached impersonal” caring. The first refers to encounters marked by openness, and unrestricted respect toward patients as human beings. The latter to encounters experienced as uncontrolled and unsecure, with elevated risks and potential for violence	Contributory conditions: lack of engagement, understanding, and impersonal care; lack of dialogue; ignored; rigid rules and routines Preventive conditions: sensitive, attentive, and caring staff; respect, real dialogues
Duxbury and Whittington (2005)^Citation6	To compare the views of patients and staff on causes of aggression and to explore perspectives on management approaches	82 inpatients, female (n=42), from three mental health care wards: a psychiatric intensive care unit, a high dependency ward, and an acute ward, UK	Mixed method. Quantitative survey with questionnaire. Qualitative follow-up interviews with a subsample of patient respondents (n=5). Content analysis for semi- structured interviews	Interviews: patients were dissatisfied with a restrictive and under-resourced provision that leads to interpersonal tension (interviews)	Contributory conditions: rigid and hierarchical ward structure; not supportive, sensitive, and responsive; lack of care and respect Preventive conditions: real dialogues
Hinsby and Baker (2004)^Citation7	To explore patients’ and nurses’ accounts of violent incidents	Four male patients from a medium- secure unit, UK	Qualitative, semi-structured interviews. Analyzed by both grounded theory and a discursive approach	Despite an increased sensitivity to contextual factors, they generally were able to control their behavior but occasionally reacted violently to an overload of environmental stressors. Institutional control exercised during violent incidents perceived as punishment	Contributory conditions: mental symptoms; unpredictable and hostile milieu; rigid and hierarchical ward structure
Ilkiw-Lavalle and Grenyer (2003)^Citation30	To examine the views of patients and staff involved in incidents of aggression to help understand emotions experienced, perceptions of causes, current management and ways of reduction	29 patients from four psychiatric inpatient units involved in incidents of aggression over a 4-month period, Australia	Mixed method, semi-structured interviews analyzed with phenomenological “bracketing” of the researchers’ expectations. Significant statements were organized into themes	Patients perceived illness, interpersonal factors, and environmental factors as being almost equally responsible for their aggression, and nearly all patients emphasized the need for improved staff–patient communication and more flexible unit rules in helping reduce aggression None of the patients reported a formal defusing or debriefing session	Contributory conditions: mental symptoms; unpredictable and hostile milieu; lack of dialogue; rigid and hierarchical ward structure Preventive conditions: reliable and meaningful activities; real dialogues
Johnson et al (1997)^Citation31	To increase the understanding of the experiences of individuals with thought disorders, which precede incidents of aggression	12 patients from two psychiatric hospitals: a tertiary care psychiatric hospital and a general hospital with a psychiatric unit, Canada	Qualitative, individual interviews, analyzed according to the method described by Giorgi, which was adapted to an approach to content analysis	Participants perceived themselves to be strongly affected by the external environment. They perceived themselves to be both powerful and powerless. The aggressive incident occurred in spite of the participants’ acknowledgment and previous use of anger-controlling strategies	Contributory conditions: lack of privacy and space; locked up; unpredictable and hostile milieu; not understood, misinterpreted, and ignored Preventive conditions: self-protecting strategies; seeking protection from staff; avoiding risky situations
Johnson and Delaney (2007)^Citation32	To understand the context and conditions that influence how nursing staff manage patients who are escalating out of control	12 patients, six female, age range 22–56 years, from two locked psychiatric units, all involved at some point in escalating situations, USA	Qualitative, observation study and interviews guided by grounded theory. Data collection and analysis conducted simultaneously as consistent with grounded theory methods	Although a particular incident has appeared suddenly and without a seemingly precipitant, patients revealed in interviews causes that might be unknown to staff. Several instances of low-level irritation hours or days before the eruption	Contributory conditions: mental symptoms; negative feelings toward staff and ward Preventive conditions: seeking protection from staff
Kumar et al (2001)^Citation8	To elicit service users’ experience of violence within the mental health system	Six outpatients, four male, with a history of hospitalization and experiences of violence as perpetrators, witness, and/or victims, UK	Qualitative, focus group, 90 minutes, recorded. Grounded theory approach, guided by Strauss and Corbin	Six core themes were identified: i) “imbalance of power” (exists in the mental health system), ii) violence has psychological sequelae, iii) mental health services are not geared to help victims of “institutional violence”, iv) the present mental health system fosters violence, v) a radical change is needed in the infrastructure of the mental health system, and vi) reinforcement and reforms may come from parallel efforts	Contributory conditions: unpredictable and hostile milieu; early signs ignored; lack of respect; not supportive, sensitive and responsive; rigid and hierarchical ward structure; not understood, misinterpreted, and ignored by staff Preventive conditions: staff training; real dialogues; debriefing after incidents
Meehan et al (2006)^Citation9	To elicit patients’ perceptions and experiences of aggressive behavior in the ward and potential strategies to minimize such behavior	27 patients, five female, from two wards on a high-secure forensic unit, Australia	Qualitative, five focus group discussions with 4–7 participants. Semi- structured interview schedule. Content analysis	Cause of aggression: the environment, empty days, staff interactions, medical issues, and patient-centered factors Strategies for prevention: early intervention, provision of meaningful activities, separation of acutely disturbed patients, improved staff attitudes, implementation of effective justice procedures, and patient advocate	Contributory conditions: unpredictable and hostile milieu; lack of privacy and space; lack of meaningful activities; rigid and hierarchical ward structure; not understood, misinterpreted, and ignored by staff; mental symptoms Preventive conditions: giving staff warning signals; debriefing of incidents; separate violent and nonviolent patients; reliable and meaningful activities; staff training; response on early warning signals
Omerov et al (2004)^Citation33	To compare staff members’ and psychotic patients’ experiences of the same violent incident	41 patients, 24 women, age range 20–65 years, from two psychosis wards. Participants had been involved in violent incidents, Sweden	Mixed method, qualitative interviews conducted with patients according to questionnaire. Statistical analysis	37 patients (90%) reported being provoked prior to the incident, by staff (73%), medication (34%), or by relatives/other patients (17%). Staff members were able to identify <50% of the provocations experienced by the patients	Contributory conditions: rigid and hierarchical ward structure; not supportive, sensitive, and responsive; lack of respect Preventive conditions: stable and professional staff; response on early warning signals
Quirk et al (2004)^Citation26	Focus on how service users cope in acute psychiatric wards and strategies used to manage the risk they face or pose to others	Study A: users on three acute wards in different psychiatric hospitals during a period of 3 years. Study B: users at 96 psychiatric units, including 73 acute wards, UK	Ethnographic study. Study A: grounded theory approach guided data collection, sampling, and analysis. Study B: content analysis with use of NUD*IST software	Many risks, such as physical assault, are attributable to other patients. Interplay between a range of interactional and contextual factors, that is, low staffing levels/minimal or poor surveillance. Users were found to employ strategies to manage risk on the ward	Contributory conditions: unpredictable and hostile milieu; lack of privacy and space; not taken seriously; lack of sensitivity and respect Preventive conditions: self-protecting strategies; de-escalation

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