Aggression Training & Perceived Safety in Psychiatric Nursing

In healthcare settings, aggressive behavior exhibited by acutely ill clients is a pervasive problem that contributes to poor outcomes for both patients and medical staff. It is widespread in inpatient mental health wards, where 7.8 cases are reported per 100 medical workers yearly, with nurses being the most likely victims (United States Bureau of Labor Statistics [USBLS], 2018). The agency further links the high risk of physical and verbal aggressive acts to a severe psychiatric diagnosis, use of restraints, substance abuse, and anticonvulsants taken by epileptic patients.

Patient aggression towards the nursing staff is recognized as a significant impediment to quality care delivery in psychiatric hospitals. Odes et al. (2020) establish that the experience of violent acts has adverse physical and psychological effects on healthcare workers, limiting their capacity to perform their role. Severe incidents may necessitate days off and affect staff safety and morale to provide adequate therapeutic are required for patient recovery. In the US, 69% of non-fatal aggressive acts by patients in clinical settings require day offs (USBLS, 2018). Hence, providing education on aggression management is important to improve nurses’ perception of safety, which will enhance the quality of care provided and empower them to safely manage aggressive patients.

Problem Statement

Patient-initiated aggression is a major problem in psychiatric units since patients are not likely to accept treatment voluntarily. While traditional methods such as seclusion and restraints may be used to curb aggressive behavior, they are less effective and exacerbate frustration, anger, and aggression (Weltens et al., 2021). Registered nurses (RNs) provide continuous direct care to patients admitted to psychiatric wards, and thus, are at a higher risk of aggression than other healthcare workers. Aggressive behavior by patients negatively impacts nurse wellbeing and performance. The experience of violent acts may make nurses feel unsafe to deliver quality psychiatric care needed for recovery and increase burnout, which leads to high turnover (Weltens et al., 2021). Therefore, patient-initiated violence is an occupational hazard that impacts clinical outcomes for both patients and RNs.

The study setting is a psychiatric health facility where reported patient-initiated aggressive incidents towards registered nurses are high. Although not documented, these violent acts have caused physical injury to patients and nurses, leading to prolonged day-offs. Further, as many as 21% of the patients admitted to this facility are pre-trial individuals with a history of substance abuse. According to Odes et al. (2020), patients legally required to receive mental healthcare services for recovery from substance use may exhibit heightened aggression towards caregivers. RNs in this facility feel less confident or afraid to work with such aggressive patients. This fear is a barrier to effective communication and treatment. In addition, the current approaches have not been effective in managing aggressive behavior and acts. The RNs also exhibit poor prevention and communication skills that are crucial in quelling anger before it escalates into aggression.

RNs provide important therapeutic care required for the recovery of patients with psychiatric conditions. However, there is a knowledge gap on effective de-escalation and defense techniques for dealing with aggression to create a safe environment for both nurses and patients. Providing an educational intervention focusing on risk identification, de-escalation, and communication is necessary to help enhance RNs’ perceptions of safety at the facility. As a result, they will be confident and competent in curbing aggression and reducing the risk of harm to themselves and the patient.


The following PICO statement has been formulated for this research: The effect of aggressive management training in improving the perception of safety in psychiatric nursing staff. The specific PICO elements include:

  • Patient (P) – psychiatric nursing staff
  • Intervention (I) – aggressive management training
  • Comparison (C) – no aggressive management training
  • Outcome (O) – increased perception of safety


Odes, R., Chapman, S., Harrison, R., Ackerman, S., & Hong, O. (2020). Frequency of violence towards healthcare workers in the United States’ inpatient psychiatric hospitals: A systematic review of literature. International Journal of Mental Health Nursing, 30(1), 27-46.

United States Bureau of Labor Statistics. (2021). Incidence rates of nonfatal occupational injuries and illnesses by industry and case types, 2020. Web.

Weltens, I., Bak, M., Berhagen, S., Vandenberk, E., Domen, P., van Amelsvoort, T., & Drukker, M. (2021). Aggression on the psychiatric ward: Prevalence and risk factors. A systematic review of the literature. Plos One, 16(10), 1-34.

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