Staff survey results and characteristics that predict assault and injury to personnel working in mental health facilities

The purpose of this study was to complete a mental health staff opinion survey to identify patient and staff characteristics associated with staff assault and injury in psychiatric treatment settings and to develop a model of prediction for staff assault and injury utilizing these survey variables. The data consisted of opinion surveys sent to staff of 15 child, adolescent, and adult psychiatry inpatient units in the United States. Multivariate logistic regression was used to determine the level of assault and staff‐reported injury prediction that could be obtained from the staff‐completed opinion survey. Responses indicated a high prevalence of reported aggression, with 62.3% of staff endorsing verbal and physical aggression, property destruction, and self‐injurious behavior as being prevalent at their site, whereas only 4.1% rated none of these as prevalent. Staff working with children and adolescents in settings with high rates of psychiatric diagnoses reported increased frequency of assault and injury compared with those working with adults. Younger, less experienced staff reported higher rates of assault and injury. Staff working with female patients reported similar rates of assault and injury to those working with males. A logistic regression analysis using staff‐reported survey results of both staff and patient characteristics predicted assault correctly 73.7% of the time and injury 66.1% of the time. Resources for violence prevention and staff training programs in violence prevention are needed in child and adolescent psychiatry wards. Results are consistent with theories emphasizing the importance of negative emotions and affects, impulsivity, and frustration in goal‐directed activities in human aggression. Aggr. Behav. 29:31–40, 2003. © 2003 Wiley‐Liss, Inc.     

Enhancing Program Quality in a National Sample of After‐school Settings: The Role of Youth–Staff Interactions and Staff/Organizational Functioning

Using multilevel data from the national evaluation of Boys and Girls Clubs of America (BGCA), this study examined associations among programmatic structures, workplace and workforce characteristics, and relational practices of program staff as they relate to young people's ratings of their experience attending local clubs. The sample included 57,710 members and 5,231 staff members at 740 BGCA sites throughout the United States. Staff relational practices—including establishing caring relationships, setting high expectations, positive behavior management, encouraging youth input and agency, and cultural sensitivity—explained associations between staffing and organizational functioning and youths’ perceptions of the quality of their clubs. Findings suggest a central role of staff relational practices in establishing conditions that youth experience positively, and that staffing and organizational processes, including community engagement and teamwork and efficiency can be viewed as foundations for establishing a culture of positive adult‐youth interaction, which in turn can contribute to the promotion of positive youth development. Further, identification with the experiences of youth had a direct association with youths’ perceptions of club quality. These results underscore the importance of staff workforce development initiatives as key to improving youth experiences in after‐school programs.     

The Scope of Client Aggression Toward Social Workers in Israel

The phenomenon of client violence toward social workers has been documented in various parts of the world. The goal of this study is to describe the phenomenon and explore the relationship pattern between contextual variables and clients’ aggression. The study encompassed a sample of 645 workers in 34 municipal social service agencies. Of the entire sample, 80% reported being exposed to some form of aggression at least once over the last 3 months. The findings highlight 2 broad axes related to client aggressiveness: frequency and level of aggression. With respect to frequency, we can discern a continuum running from common types of aggressive behaviors to rare ones. The other axis focuses on the level of aggressiveness used, from minor types of client aggression, such as verbal assaults and threats, increasing to more severe ones, such as property damage, and, finally, to physical injury. The routineness of aggression in the work environment lends it the appearance of being normal, and functioning in such an environment desensitizes social workers to clients’ aggressiveness. Also examined and discussed are organizational and personal factors that contribute to the aggressive behavior of clients, including seniority, gender, workload, inadequate service conditions, and coworkers’ aggressive behavior.     

Psychiatric nurses' experiences with inpatient aggression

Using a survey instrument, the experiences of psychiatric nurses with inpatient aggression were investigated in East London, U.K. On this “Perceptions of Prevalence Of Aggression Scale” (POPAS), annual experiences with 15 types of disruptive and aggressive behavior were rated anonymously. Staff members were also asked to disclose the number of days missed from work due to inpatient violence. On the basis of these POPAS forms, internal consistency of the instrument, mean reported aggression frequencies, and days missed from work due to violence were calculated. Internal consistency of the POPAS appeared to be reasonable. Verbal abuse and threats were experienced by most of the psychiatric nurses during a one‐year period (i.e., by about 80–90 percent of nurses). Sexual harassment or intimidation was also experienced relatively often on an annual basis (68 percent), particularly by female and young staff members. A minority of staff members (i.e., 16 percent) had experienced severe physical violence. Although not prevalent, this type of behavior was most strongly connected with reporting sick. In particular, staff members working with involuntarily admitted patients experienced much (severe) violence during their work. Although the validity of estimates of aggression prevalence with the POPAS instrument needs to be investigated further, such a survey may be helpful in gaining insight rather quickly into the level of day‐to‐day contact with aggressive behavior. Also, since information on verbal, physical, and sexual violence, and on days missed from work, can be provided anonymously, this rather delicate, but essential management information, may be accessed relatively easily with the POPAS. Aggr. Behav. 00:000–000, 2005. © 2005 Wiley‐Liss, Inc.     

Situational determinants of inpatient self-harm

Auto-aggressive individuals have a higher likelihood of engaging in interpersonal violence, and vice versa. It is unclear, however, whether ward circumstances are involved in determining whether aggression-prone patients will engage in auto-aggressive or outwardly directed aggressive behavior. The current study focuses on the situational antecedents of self-harming behavior and outwardly directed aggression of psychiatric inpatients. Inwardly and outwardly aggressive behavior were monitored on a locked 20-bed psychiatric admissions ward for 3.5 years with the Staff Observation Aggression Scale-Revised (SOAS-R). A map of the ward was attached to each SOAS-R form, enabling staff members to specify locations of aggressive incidents. Time of onset, location, and provoking factors of auto-aggressive incidents were compared to those connected to aggression against others or objects. Of a total of 774 aggressive incidents, 154 (20%) concerned auto-aggressive behavior. Auto-aggression was significantly more prevalent during the evening (i.e., 50% compared to 32%), and reached its highest level between 8 and 9 P.M. (17% compared to 7%). The majority of self-harming acts (66%) were performed on patients' bedrooms. Outwardly directed aggression was particularly common in the day-rooms (24%), the staff office (19%), the hallways of the ward (14%), and the dining rooms (10%). Provoking factors of auto-aggressive behavior are less often of an interactional nature compared to outwardly directed aggression. The results suggest that a lack of stimulation and interaction with others increases the risk of self-injurious behavior. Practical and testable measures to prevent self-harm are proposed.     

Food and violence: Childhood violence and emotional abuse as complicating factors in the inpatient treatment of eating disorders

SUMMARY

This paper considers the treatment, on an inpatient eating disorders ward, of patients who have suffered violence and emotional abuse during childhood. The complex web of relationships surrounding these patients is discussed, and it is suggested that there are multiple transferences — to the institution, to various members of staff, and to other patients — and that splitting of these transferences is inevitable. Staff experience powerful countertransference feelings, related to the patient's violent history. A central task for the staff team as a whole is to understand and contain the patient's disturbance — taking on, tolerating, and processing the projections. This demands the close working-together of the members of the multidisciplinary team, so that staff can together openly examine the patient's interaction with them and their own emotional responses to the patient and to other members of staff. If these responses are not understood by the ward staff, they can lead to conflict and inappropriate decisions. On the other hand, if the staff team together can build up a picture of the patient's relationships on the ward, and their meaning for the patient, this picture, like a particular projection of the world in an atlas, provides a ‘map’ of the patient's inner world. This ‘map’ can be used by the staff team in navigating their interactions with the patient. It can also assist the psychotherapist in her work to help the patient recognise and, eventually, own the split-off parts of herself.     

PYRAMIDAL STAFF TRAINING IN THE EXTENSION OF TREATMENT FOR SEVERE BEHAVIOR DISORDERS

We implemented a pyramidal training procedure for staff working with individuals who exhibited self-injurious behavior (SIB), aggression, and disruption. Two adults with developmental disabilities and their direct-care staff and supervisors participated. Following successful treatment by the experimenters, two types of baselines were conducted with the clients and their direct-care staff. During an initial baseline, the staff implemented preexisting procedures. Staff members then received instruction on the new treatment procedures using training methods common throughout the institution, and data were collected during this “post-in-service” baseline. Experimenters then taught unit supervisors to implement treatment, collect and interpret data, and provide similar instructions and feedback to the staff members. The supervisor training was implemented in a multiple baseline design across subjects (clients and direct-care staff). Results showed little change following in-service training but noticeable improvements in direct-care staff behaviors and corresponding decreases in the clients' inappropriate behavior following the pyramidal training intervention with supervisors. Six additional clients (along with their direct-care staff and supervisors) participated in pre- and posttreatment replication designs, and their results provided additional support for the efficacy of the supervisor training procedures.     

Autonomic functioning in reactive versus proactive aggression: The influential role of inconsistent parenting

Research has consistently supported autonomic nervous system (ANS) functioning as a predictor of aggressive behavior in youth. Several studies have further examined how the functioning of the sympathetic (SNS) and parasympathetic (PNS) branches of the ANS interact with environmental factors to predict behavioral outcomes. One factor that has yet to be studied in this context however, is parenting practices. Given that many interventions for externalizing behavior target parenting practices, such as increasing consistent discipline, it may be particularly important to assess whether parenting practices interact with SNS and PNS functioning in the child to influence risk for aggressive behavior. Therefore, the current study addressed this question by examining inconsistent discipline as a moderator of the relationship between baseline SNS versus PNS activity and reactive versus proactive aggression. Data were collected from a sample of fourth graders identified as at‐risk for aggression (N = 188). Results indicated that baseline SNS activity was positively related to proactive aggression under high levels of inconsistent discipline, but negatively related to proactive aggression under very low levels of inconsistent discipline. Baseline PNS activity was negatively associated with reactive aggression under low levels of inconsistent discipline. No main effects were found for SNS or PNS functioning and either form of aggression, emphasizing the importance of taking a biosocial approach to examining the predictors of aggressive behavior in at‐risk youth. Results from this study help to better understand the circumstances under which children are most likely to exhibit reactive versus proactive aggression, better informing targeted prevention and treatment.

     

Broaching the Subjects of Race,Ethnicity, and Culture During the Counseling Process

The authors define broaching as the counselor's ability to consider how sociopolitical factors such as race influence the client's counseling concerns. The counselor must learn to recognize the cultural meaning clients attach to phenomena and to subsequently translate that cultural knowledge into meaningful practice that facilitates client empowerment, strengthens the therapeutic alliance, and enhances counseling outcomes. A continuum of broaching behavior is described, and parallels are drawn between the progression of broaching behavior and the counselor's level of racial identity functioning.     

Putative behavioral history effects and aggression maintained by escape from therapists

Differentially higher rates of aggression in treatment sessions occurred in the presence of two staff members who had previously worked with the participant at another facility. Adding an edible reinforcer for compliance and the absence of aggression in sessions conducted by these two staff members decreased aggression to rates similar to those obtained with less familiar therapists. Results suggest that embedding positive reinforcement within a demand context may reduce the aversiveness of therapists correlated with a history of demand situations.     

Effects of outcome performance feedback on maintenance of client and staff behavior in a residential setting

This study examined effects of outcome performance feedback on maintenance of client and direct care staff behavior in a group home for four clients with severe/profound intellectual disability. Following baseline observations, 8 staff were instructed to prompt and praise interclient interactions and game activity during leisure sessions. Staff training comprised written instructions, in situ modeling and rehearsal, and performance feedback. This was followed by a 17-week maintenance period, during which staff received outcome performance feedback based on independent and self-recorded observations. Results showed that client gains were maintained, but did not stabilize. It was concluded that process feedback should have accompanied outcome feedback until staff behavior levels suitable for durable maintenance were obtained. In addition, successful use of performance feedback as a maintenance tool is highly dependent on which outcome behaviors are selected, and whether these are eventually naturally reinforced.     

Toward a reorientation of research on aggression

A number of studies are reported which sustain the importance of individual differences in the study of aggression. Irritability, emotional susceptibility, dissipatio—nrumination, tolerance toward violence, and proneness to guilt feelings provide a better understanding of the various forms of aggression. Prosocial behaviour, emotional instability, and physical and verbal aggression proved to be important indicators to children's more general adjustment. To go beyond the traditional paradigm of research on aggression a structural and interactive—interpersonal analysis of aggression is recommended. Aggression as a unitary phenomenon is called into question. Instead, it is stated that the various facets of aggression find an explanation and acquire meaning within the context of global personality development and functioning.     

Physical aggression as a function of strength of frustration and instrumentality of aggression

Direct physical aggression was related to three variables through a modification of the Buss (1961) “aggression machine” and procedure. There were two intensities of frustration and a control group established on the basis of the goal gradient principle. Aggression was either instrumental or noninstrumental in overcoming the frustration. Frustration was arbitrary (unreasonable) or nonarbitrary (reasonable). More aggression occurred under the instrumental condition than under the noninstrumental condition. The stronger frustration produced more aggression than the weaker frustration, but only when aggression had previously been experienced as instrumental. No more aggression occurred under the arbitrary frustration condition than under the nonarbitrary condition. The results were discussed in relation to the frustration-aggression hypothesis and the goal gradient principle.     

Staff-administered functional analysis and treatment of aggression by an elder with dementia

In the current study, nursing home staff were taught to administer functional analyses to determine the variables maintaining aggression by an elder with dementia. The results indicated that aggression was evoked during bathroom routines and that escape maintained aggression. Staff then reduced aggression to near-zero levels with noncontingent escape. Implications for the assessment and treatment of problem behaviors in nursing home settings are discussed.     

VALIDATING PREDICTED ACTIVITY PREFERENCES OF INDIVIDUALS WITH SEVERE DISABILITIES

We examined the accuracy of 24 staff members' predictions of activities preferred by 14 individuals with severe disabilities. For each of 144 activities, staff members assigned a client preference rating of “likes a lot,” “likes,” or “dislikes.” Two activities from each category were randomly selected for each individual with disabilities. Pairs of selected activities were presented to the individuals, who were prompted to choose an activity. Staff members' activity preference ratings correctly predicted the choices made by the individuals with disabilities for 78% of the trials. The more divergent the preference ratings of the paired activities, the more likely staff members were to predict correctly the activity selected by a participant.     

Chinese children's effortful control and dispositional anger/frustration: relations to parenting styles and children's social functioning

Relations among authoritative and authoritarian parenting styles, children's effortful control and dispositional anger/frustration, and children's social functioning were examined for 425 first and second graders (7-10 years old) in Beijing, China. Parents reported on parenting styles; parents and teachers rated children's effortful control, anger/frustration, externalizing problems, and socially appropriate behaviors: and peers rated aggression and leadership/sociability. High effortful control and low dispositional anger/frustration uniquely predicted Chinese children's high social functioning, and the relation of anger/frustration to social functioning was moderated by effortful control. Authoritarian parenting was associated with children's low effortful control and high dispositional anger/frustration, which (especially effortful control) mediated the negative relation between authoritarian parenting and children's social functioning. Effortful control weakly mediated the positive relation of authoritative parenting to social functioning.     

MOTIVATING STAFF PERFORMANCE IN AN OPERANT LEARNING PROGRAM FOR CHILDREN

Staff performance in a residential child-treatment facility was measured by counting the number of jobs completed and number of new procedures implemented within one week of their assignment. Public notices were posted listing each staff member's duties and new procedures to be implemented during the week. The notices produced an immediate increase in performance levels, which quickly tapered off. Staff members were then given tokens worth $1.00 each for performing jobs and implementing procedures within one week of assignment. The tokens regained and sustained high levels of performance when used in conjunction with the public notices. The use of public notices alone and tokens alone maintained better performance than baseline levels, but neither was as effective in starting and maintaining high-performance levels as was the combined use of the two.     

Simultaneously Testing Parenting and Social Cognitions in Children At-Risk for Aggressive Behavior Problems: Sex Differences and Ethnic Similarities

In this cross-sectional study we examined a model in which parenting, child social information processing and self-perception are simultaneously tested as risk factors associated with aggression. Sex and ethnicity were tested as moderators of associations. The sample consisted of 206 4th grade children in the Netherlands. Parents reported on parenting, parent–child relationship, and reactive and proactive aggression whereas children reported on self-perception and social information processing. Results give support for both child social cognitive functioning and parenting as risk factors associated with aggressive behavior: For all children, a positive parent–child relationship was associated with less aggression, negative parenting was related to less positive self-perception, and deficits in social-cognitive functioning were related to aggression. Multigroup analyses showed ethnic similarities and sex differences in patterns of associations, which might suggest personalized tailor-made interventions for aggressive behavior.     

Proactive and reactive aggression in delinquent adolescents: relations to aggression outcome expectancies

Investigated whether the relation between aggression and the tendency to expect positive outcomes for aggressive behavior is specific to the proactive subtype of aggression (as opposed to the reactive subtype). In a sample of 86 incarcerated adolescent boys ages 13 to 18, we measured outcome expectancies for aggression using audiotaped hypothetical vignettes. For each participant, staff members completed proactive and reactive aggression rating scales. Regression analyses revealed that the relation between aggression and outcome expectancies was indeed specific to proactive aggression. Furthermore, this finding was supported regardless of whether outcome expectancies were assessed using vignettes describing proactive-aggressive behavior or those describing reactive-aggressive behavior. We discuss these findings and argue that interventions to reduce proactive or reactive aggression should differ from each other by addressing the specific social cognitive processes involved in each type of aggression.     

Intellectual functioning and aggression

In a 22-year study, data were collected on aggressiveness and intellectual functioning in more than 600 subjects, their parents, and their children. Both aggression and intellectual functioning are reasonably stable in a subject's lifetime and perpetuate themselves across generations and within marriage pairs. Aggression in childhood was shown to interfere with the development of intellectual functioning and to be predictive of poorer intellectual achievement as an adult. Early IQ was related to early subject aggression but did not predict changes in aggression after age 8. On the other hand, differences between early IQ and intellectual achievement in middle adulthood were predictable from early aggressive behavior. A dual-process model was offered to explain the relation between intellectual functioning and aggressive behavior. We hypothesized that low intelligence makes the learning of aggressive responses more likely at an early age, and this aggressive behavior makes continued intellectual development more difficult.