Anger: Its Role and Relation to Aggression and Coercive Containment in Secure Adult Mental Health Services

BACKGROUND: Inpatient aggression is common in mental health services resulting in significant costs. Anger is an important risk factor, but research into the role of its constituents is limited. The role of nursing staff's anger in their reactions to aggressive patients is poorly understood. AIMS: This thesis examined the role of anger and its components in patient aggression and nursing staff’s coercive containment practices. Objectives were to: i) better understand the relationship between patient anger and aggression; ii) identify whether patients’ self-reported anger adds value to violence-risk assessment tools; iii) determine whether nursing staff anger is related to exposure to inpatient aggression and in their attitudes towards and involvement in coercive containment; iv) determine how anger is manifested in the interpersonal styles of both patients and nursing staff, and identify whether any specific nurse-patient interpersonal relationship-type is associated with inpatient aggression and/or coercive containment. METHODS: Two systematic literature reviews were conducted on patient anger and nursing staff anger, respectively. Correlational study designs were adopted across four empirical studies using validated questionnaires and cognitive tasks. Aggression and containment incident data and clinician-rated violence risk assessments were retrieved. RESULTS: Patients (n = 93) and nursing staff (n = 68) from low and medium secure mental health services were recruited. Using explicit cognitive processing measures, patient anger was associated with hostility and rumination tendencies. Patients’ selfreported anger was significantly positively correlated with clinician-rated, anger-related violence risk assessment items, and predicted inpatient aggression but not beyond clinicians’ ratings. Nursing staff anger was associated with exposure to patient aggression perceived as humiliating; nursing staff who reported higher levels of anger approved more of physical restraint. Patients’ self-reported anger was related to their nurse-rated hostile interpersonal style while nurses’ self-reported anger was related to their patient-rated dominant interpersonal style. CONCLUSIONS: Implications of this programme of research demonstrates that anger plays an important role in the occurrence and management of inpatient aggression. They provide significant new knowledge to incorporate into evidence-based anger treatment programmes and staff training and support.