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Coercive practices, such as physical restraint, are used globally to respond to violent, aggressive and other behaviours displayed by mental health service users.1 A number of approaches have been designed to aid staff working within services to minimise the use of restraint and other restrictive practices. One such approach, the ‘REsTRAIN Yourself’ (RYS) initiative, has been evaluated in the UK. Rapid ethnography was used to explore the aspects of organisational culture and staff behaviour exhibited by teams of staff working within 14 acute admission mental health wards in the North West region of the English NHS. Findings comprise four core themes of space and place; legitimation; meaningful activity; and, therapeutic engagement that represent characteristics of daily life on the wards before and after implementation of the RYS intervention. Tensions between staff commitments to therapeutic relations and constraining factors were revealed in demarcations of ward space and limitations on availability of meaningful activities. The physical, relational and discursive means by which ward spaces are segregated prompts attention to the observed materialities of routine care. Legitimation was identified as a crucial discursive practice in the context of staff reliance upon coercion. Trauma‐informed care represents a potentially alternative legitimacy.

Previous research illustrated that the laws regulating involuntary placement and treatment of people with mental-health problems are diverse across countries. International studies comparing satisfaction levels between countries are rare. We compared the opinions of professionals and family members about the operation of the national mental-health law regulating forcibly admission and treatment of psychiatric patients in 11 countries: Ireland, Iceland, England and Wales, Romania, Slovenia, Denmark, Germany, Sweden, Norway and India. An online survey design was adopted using a Mental Health Legislation Attitudes Scale (MHLAS). This brief nine-item questionnaire was distributed via email to psychiatrists, general practitioners, acute and community mental-health nurses, tribunal members, police officers and family members in each collaborating country. The levels of agreement/disagreement were measured on a Likert scale. Data were analysed both per question and with regard to a total MHLAS ‘approval’ score computed as a sum of the nine questions. We found that respondents in England and Wales and Denmark expressed the highest approval for their national legislation (76% and 74%, respectively), with those in India and Ireland expressing the lowest approval (65% and 64%, respectively). Almost all countries had a more positive attitude in comparison to Ireland on the admission criteria for involuntary placement and the way people are transferred to psychiatric hospitals. There are significant variations across Europe and beyond in terms of approval for how the national mental-health law framework operates in each country.

International efforts to minimize coercive practices include the US Six Core Strategies© (6CS). This innovative approach has limited evidence of its effectiveness, with few robustly designed studies, and has not been formally implemented or evaluated in the UK. An adapted version of the 6CS, which we called ‘REsTRAIN Yourself’ (RY), was devised to suit the UK context and evaluated using mixed methods. RY aimed to reduce the use of physical restraint in mental health inpatient ward settings through training and practice development with whole teams, directly in the ward settings where change was to be implemented and barriers to change overcome. In this paper, we present qualitative findings that report on staff perspectives of the impact and value of RY following its implementation. Thirty‐six staff participated in semi‐structured interviews with data subject to thematic analysis. Eight themes are reported that highlight perceived improvements in every domain of the 6CS after RY had been introduced. Staff reported more positively on their relationships with service users and felt their attitudes towards the use of coercive practices such as restraint were changed; the service as a whole shifted in terms of restraint awareness and reduction; and new policies, procedures, and language were introduced despite certain barriers. These findings need to be appreciated in a context wherein substantial reductions in the use of physical restraint were proven possible, largely due to building upon empathic and relational alternatives. However, yet more could be achieved with greater resourcing of inpatient care.

Introduction: Safe staffing and coercive practices are of pressing concern for mental health services. These are inter-dependent and the relationship is under-researched. Aim: To explore views on staffing levels in context of attempting to minimise physical restraint practices on mental health wards. Findings emerged from a wider dataset with the broader aim of exploring experiences of a restraint reduction initiative Methods: Thematic analysis of semi-structured interviews with staff (n=130) and service users (n=32). Results: Five themes were identified regarding how staffing levels impact experiences and complicate efforts to minimise physical restraint. We titled the themes – ‘insufficient staff to do the job’; ‘detriment to staff and service users’; ‘a paperwork exercise: the burden of non-clinical tasks’; ‘false economies’; and, ‘you can’t do these interventions’. Discussion: Tendencies detracting from relational aspects of care are not independent of insufficiencies in staffing. The relational, communicative, and organisational developments that would enable reductions in use of restraint are labour intensive and vulnerable to derailment by insufficient and poorly skilled staff. Implications for Practice: Restrictive practices are unlikely to be minimised unless wards are adequately staffed. Inadequate staffing is not independent of restrictive practices and reduces access to alternative interventions for reducing individuals’ distress.

Background Physical restraint is a coercive intervention used to prevent individuals from harming themselves or others. However, serious adverse effects have been reported. Minimising the use of restraint requires a multimodal approach to target both organisational and individual factors. The ‘Six Core Strategies’ developed in America, underpinned by prevention and trauma informed principles, is one such approach. Objective An adapted version of the Six Core Strategies was developed and its impact upon physical restraint usage in mental health Trusts in the United Kingdom evaluated. This became known as ‘REsTRAIN YOURSELF. The hypothesis was that restraint would be reduced by 40% on the implementation wards over a six-month period. Design A non-randomised controlled trial design was employed. Setting Fourteen, adult, mental health wards from seven mental health hospitals in the North West of England took part in the study. Two acute care wards were targeted from all eligible acute wards within each site in negotiation with each Trust. The intervention wards (total n = 144 beds, mean = 20.1 beds per ward) and control wards (total n = 147 beds, mean = 21.0 beds per ward) were primarily mixed gender but included single sex wards also (2 female-only and 1 male-only in each group). All wards offered pharmacological and psychosocial interventions over short admission durations (circa 15 days) for patients with a mixture of enduring mental health problems. Method As part of a pre and post-test method, physical restraint figures were collected using prospective, routine hospital records before and 6 months after the intervention. Restraint rates on seven wards receiving the REsTRAIN YOURSELF intervention were compared with those on seven control wards over three study phases (baseline, implementation and adoption). Results In total, 1680 restraint incidents were logged over the study period. The restraint rate was significantly lower on the intervention wards in the adoptio

Previous research illustrated that the laws regulating involuntaryplacement and treatment of persons with mental health problems arevery diverse across countries. International studies comparingsatisfaction levels between countries are rare. We compared the opinionsof professionals and family members about the operation of the nationalmental health law regulating forcibly admission and treatment ofpsychiatric patients in eleven countries: Ireland, Iceland, England &Wales, Romania, Slovenia, Denmark, Germany, Sweden, Norway andIndia. An online survey design was adopted using a Mental HealthLegislation Attitude Scale (MHLAS). This brief 9-item questionnaire wasdistributed via e-mail to psychiatrists, general practitioners, acute andcommunity mental health nurses, tribunal members, police officers and family members in each collaborating country. The levels ofagreement/disagreement were measured on a Likert- scale. Data wereanalysed both per question and with regard to a total MHLAS ‘approval’score computed as a sum of the 9 questions. We found that respondentsin England & Wales and Denmark expressing strongest approval for theirnational legislation (76 and 74% respectively), with those in India andIreland expressing the least approval (65 and 64% respectively). Almostall countries had a more positive attitude in comparison with Ireland onthe admission criteria for involuntary placement and the way people aretransferred to psychiatric hospitals. There are significant variationsacross Europe and beyond in terms of approval for how the nationalmental health law framework operates in each country.

In Western society, policy and legislation seeks to minimize restrictive interventions, including physical restraint; yet research suggests the use of such practices continues to raise concerns. Whilst international agreement has sought to define physical restraint, diversity in the way in which countries use restraint remains disparate. Research to date has reported on statistics regarding restraint, how and why it is used, and staff and service user perspectives about its use. However, there is limited evidence directly exploring the physical and psychological harm restraint may cause to people being cared for within mental health inpatient settings. This study reports on an integrative review of the literature exploring available evidence regarding the physical and psychological impact of restraint. The review included both experimental and nonexperimental research papers, using Cooper's (1998) five‐stage approach to synthesize the findings. Eight themes emerged: Trauma/retraumatization; Distress; Fear; Feeling ignored; Control; Power; Calm; and Dehumanizing conditions. In conclusion, whilst further research is required regarding the physical and psychological implications of physical restraint in mental health settings, mental health nurses are in a prime position to use their skills and knowledge to address the issues identified to eradicate the use of restraint and better meet the needs of those experiencing mental illness.

The relative burden of mental health disorders is increasing globally, in terms of prevalence and disability. There is limited data available to guide treatment choices for clinicians in low resourced settings, with mHealth technologies being a potentially beneficial avenue to bridging the large mental health treatment gap globally. The aim of the review was to search the literature systematically for studies of mHealth interventions for psychosis globally, and to examine whether mHealth for psychosis has been investigated. A systematic literature search was completed in Embase, Medline, PsychINFO and Evidence Based Medicine Reviews databases from inception to May 2016. Only studies with a randomised controlled trial design that investigated an mHealth intervention for psychosis were included. A total of 5690 records were identified with 7 studies meeting the inclusion criteria. The majority of included studies, were conducted across Europe and the United Sates with one being conducted in China. The 7 included studies examined different parameters, such as Experiential Sampling Methodology (ESM), medication adherence, cognitive impairment, social functioning and suicidal ideation in veterans with schizophrenia. Considering the increasing access to mobile devices globally, mHealth may potentially increase access to appropriate mental health care. The results of this review show promise in bridging the global mental health treatment gap, by enabling individuals to receive treatment via their mobile phones, particularly for those individuals who live in remote or rural areas, areas of high deprivation and for those from low resourced settings.

Carers of people with dementia need to embrace the philosophy of person-centred care and understand that social and psychological aspects of care are as important as physical care. This article discusses a three-component model relating to the personal qualities that carers should ideally possess to deliver person-centred care to people with dementia. These qualities are empathy with the person, person-centred attitudes and a compassionate approach. It is hoped that they will induce a state of cognitive security in people with dementia and enhance their sense of wellbeing. The article will define each of the personal qualities and detail their components. It will also discuss why person-centred care can often be difficult to achieve in practice, as well as the role of education in its promotion.

Objectives: Technological advances in healthcare have shown promise when delivering interventions for mental health problems such as psychosis. The aim of this project is to develop a mobile phone intervention for people with psychosis and to conduct a feasibility study of the TechCare App. Methods: The TechCare App will assess participant’s symptoms and respond with a personalised guided self-help-based psychological intervention with the aim of exploring feasibility and acceptability. The project will recruit 16 service users and 8–10 health professionals from the Lancashire Care NHS Foundation Trust Early Intervention Service. Results: In strand 1 of the study, we will invite people to discuss their experience of psychosis and give their opinions on the existing evidence-based treatment (cognitive behavioural therapy) and how the mobile app can be developed. In strand 2, we will complete a test run with a small number of participants (n = 4) to refine the mobile intervention (TechCare). Finally, in strand 3 of the study, the TechCare App will be examined in a feasibility study with 12 participants. Conclusion: It has been suggested that there is a need for a rapid increase in the efforts to develop the evidence base for the clinical effectiveness of digital technologies, considering mHealth research can potentially be helpful in addressing the demand on mental health services globally.

Introduction: While mechanical and manual restraint as an institutional method of control within mental health settings may be perceived to seem necessary at times, there is emergent literature highlighting the potential counter-therapeutic impact of this practice for patients as well as staff. Nurses are the professional group who are most likely to use mechanical and manual restraint methods within mental health settings. In-depth insights to understand what factors influence nurses’ decision-making related to restraint use are therefore warranted. Aim: To explore what influences mental health nurses’ decision-making in the use of restraint. Method: An integrative review using Cooper’s framework was undertaken. Results: Eight emerging themes were identified: ‘safety for all’, ‘restraint as a necessary intervention’, ‘restraint as a last resort’, ‘role conflict’, ‘maintaining control’, ‘staff composition’, ‘knowledge and perception of patient behaviours’, and ‘psychological impact’. These themes highlight how mental health nurses’ decision-making is influenced by ethical and safety responsibilities, as well as, interpersonal and staff-related factors. Conclusion: Research to further understand the experience and actualization of ‘last resort’ in the use of restraint and to provide strategies to prevent restraint use in mental health settings are needed.

Objectives: Technological advances in healthcare have shown promise when delivering interventions for mental health problems such as psychosis. The aim of this project is to develop a mobile phone intervention for people with psychosis and to conduct a feasibility study of the TechCare App. Methods: The TechCare App will assess participant’s symptoms and respond with a personalised guided self-help-based psychological intervention with the aim of exploring feasibility and acceptability. The project will recruit 16 service users and 8–10 health professionals from the Lancashire Care NHS Foundation Trust Early Intervention Service. Results: In strand 1 of the study, we will invite people to discuss their experience of psychosis and give their opinions on the existing evidence-based treatment (cognitive behavioural therapy) and how the mobile app can be developed. In strand 2, we will complete a test run with a small number of participants (n = 4) to refine the mobile intervention (TechCare). Finally, in strand 3 of the study, the TechCare App will be examined in a feasibility study with 12 participants. Conclusion: It has been suggested that there is a need for a rapid increase in the efforts to develop the evidence base for the clinical effectiveness of digital technologies, considering mHealth research can potentially be helpful in addressing the demand on mental health services globally.

Aggression is reported to be prevalent in psychiatric inpatient care and its frequency towards healthcare professionals is well documented. While aggression may not be entirely avoidable, its incidence can be reduced through prevention and the minimization of restrictive practices such as physical restraint. This paper aims to explore three common ‘defences’ to account for the use of physical restraint; to challenge each defence with regard to the evidence base; and to identify how services are responding to the challenge of reducing the use of restrictive interventions. Following a number of investigations to highlight serious problems with the use of physical restraint, it seems timely to examine its efficacy in light of the evidence base. A combination of interventions to minimize the use of restraint including advance planning tools, and recognition of potential trauma is necessary at an organizational and individual level. Patients can be traumatized by the use of restrictive practices and there is a growing momentum to promote models that incorporate trauma informed care (TIC) and person centredness.

Background: Dementia is one of the most common diseases of aging and leads to an increased need for care. Caregivers' attitudes about aggression can influence their interaction with people with dementia. To examine this further, “The Management of Aggression in People with Dementia Attitude Questionnaire” (MAPDAQ) was developed for use in nursing homes in the United Kingdom. In Switzerland, the MAPDAQ has been translated into a German Version (MAPDAQ-G), but not yet tested for its validity and reliability. Aim: Therefore the present study examined the content and face validity, comprehensibility and interpretability of MAPDAQ-G in a Swiss context. Methods: The review was based on expert surveys and interviews with caregivers in nursing homes and psychiatric hospitals. Results: According to experts, the optimised MAPDAQ-G is comprehensive (88 %) and shows good content validity (I-CVI = 0,6 – 0,1; S-CVI-Ave = 0,88). 15 items have been adapted and further validated by 16 nurses. Finally, apart from two items, the MAPDAQ-G is understood by nurses and can be interpreted consistently. Conclusions: A questionnaire of this sort allows nurses to reflect in practice upon their own attitude with regard to the management of aggression in people with dementia and to influence the quality of care. The MAPDAQ-G should be statistically tested for validity and reliability using a larger sample.

Accessible summary Delays in effective treatment of a first episode psychosis can result in more severe symptoms, a longer time to achieve symptom control and a poorer quality of life; yet around 40% do not take antipsychotic medication as prescribed. There is evidence that patients and staff have different perceptions of what affects adherence with medication. Research in adults suggests healthcare professionals and patients understand the importance of good insight in promoting adherence with medication for schizophrenia; however, healthcare staff may overestimate the impact of side effects and underestimate the importance of medication effectiveness. There is also some evidence to suggest that motivations to take prescribed medication may differ in first and multi-episode psychosis. This research therefore sought views of staff working with adolescents diagnosed with first episode psychosis about what factors affected adherence with antipsychotic medication. Staff responding to the survey felt that young people were more likely to take medication if they felt it would make them better, prevent relapse and if they had a positive rapport with staff. As in an adult population, side effects, particularly weight gain, sedation and muscular side effects, were expressed as a common reason for poor adherence. Doctors and nurses assigned differing importance to parameters such as family views of medication, fear of admission and a preference for cannabis over medication suggesting that views may differ between professional groups Views of young people will be obtained in the next phase of the research study to enable comparison with staff views and consideration of staff interventions to better promote medication adherence. Abstract Antipsychotic medication is an effective treatment for first episode psychosis; yet 40% of patients do not take medication as prescribed. Previous research in adults with schizophrenia comparing healthcare professional and patient views sugges

Accessible summary: What is known on the subject: The physical and psychological trauma that can occur as a result of physical restraint is increasingly highlighted in the media and literature across the globe. Despite this, the use of physical restraint continues without a strong evdience base for its value or efficacy. What this paper adds to existing knowledge: A number of common defences for the use of physical restraint are outlined and considered in light of existing research in this area. The potential for adopting restrictive intervention minimization programmes of work is highlighted as a way forward. What are the implications for practice: The implementation of approaches to prevent and reduce physical restraint is required. A combination of factors including the use of advance planning tools, recognition of potential injury and death, and the importance of trauma informed care is necessary. Patients can be severely traumatized by the use of restrictive practices including restraint, and there is an increasing drive to examine, reflect upon, and to reduce the use and impact of these. Aggression is reported to be prevalent in psychiatric inpatient care and its frequency towards healthcare professionals is well documented. While aggression may not be entirely avoidable, its incidence can be reduced through prevention and the minimization of restrictive practices such as physical restraint. The study aims to explore three common 'defences' to account for the use of physical restraint; to challenge each defence with regard to the evidence base; and to identify how services are responding to the challenge of reducing the use of restrictive interventions. Following a number of investigations to highlight serious problems with the use of physical restraint, it seems timely to examine its efficacy in light of the evidence base. In order to do this, three key defences for its use will be challenged using the literature. A combination of interventions to minimize th

Aggression is reported to be prevalent in psychiatric inpatient care and its frequency towards healthcare professionals is well documented. While aggression may not be entirely avoidable, its incidence can be reduced through prevention and the minimization of restrictive practices such as physical restraint. This paper aims to explore three common ‘defences’ to account for the use of physical restraint; to challenge each defence with regard to the evidence base; and to identify how services are responding to the challenge of reducing the use of restrictive interventions. Following a number of investigations to highlight serious problems with the use of physical restraint, it seems timely to examine its efficacy in light of the evidence base. A combination of interventions to minimize the use of restraint including advance planning tools, and recognition of potential trauma is necessary at an organizational and individual level. Patients can be traumatized by the use of restrictive practices and there is a growing momentum to promote models that incorporate trauma informed care (TIC) and person centredness.

Restraint and seclusion (R/S) have been used in many countries and across service sectors for centuries. With the recent and increasing recognition of the harm associated with these procedures, efforts have been made to reduce and prevent R/S. Following a scathing media exposé in 1998 and congressional scrutiny, the United States began a national effort to reduce and prevent R/S use. With federal impetus and funding, an evidence-based practice, the Six Core Strategies1 to Prevent Conflict, Violence and the Use of Seclusion and Restraint, was developed. This model was widely and successfully implemented in a number of U.S. states and is being adopted by other countries, including Finland, Australia, and the United Kingdom. Recently, the first cluster randomized controlled study of the Six Core Strategies in Finland provided the first evidence-based data of the safety and effectiveness of a coercion prevention methodology. Preliminary findings of some of the international efforts are discussed. Reduction in R/S use and other positive outcomes are also reported.

Background: A study of involvement initiatives within secure mental health services across one UK region, where these have been organised to reflect alliances between staff and service users. There is little previous relevant international research, but constraints upon effective involvement have been noted. Objective: To explore and evaluate involvement initiatives in secure mental health settings. Design: A case study design with thematic analysis of qualitative interviews and focus groups. Setting and participants: Data collection was carried out between October 2011 and February 2012 with 139 staff and service users drawn from a variety of secure mental health settings. Findings: Our analysis offers four broad themes, titled: safety and security first?; bringing it all back home; it picks you up; it’s the talk. The quality of dialogue between staff and services users was deemed of prime importance. Features of secure environments could constrain communication, and the best examples of empowerment took place in non-secure settings. Discussion: Key aspects of communication and setting sustain involvement. These features are discussed with reference to Jurgen Habermas's work on communicative action and deliberative democracy. Conclusions: Involvement initiatives with service users resident in secure hospitals can be organized to good effect and the active role of commissioners is crucial. Positive outcomes are optimized when care is taken over the social space where involvement takes place and the process of involvement is appreciated by participants. Concerns over risk management are influential in staff support. This is germane to innovative thinking about practice and policy in this field.

Background: Patient aggression is a common source of occupational violence in emergency departments. Staff attitudes regarding the causes for aggression influence the way they manage it. The Management of Clinical Aggression – Rapid Emergency Department Intervention is a 45min educational program that aims to promote the use of de-escalation techniques and effective communication skills to prevent patient aggression. Objective: We sought to evaluate the impact of the program on staff attitudes regarding the prevention and early management of patient aggression. Design: A mixed methods approach was used including a pre-test post-test survey of training participants and individual interviews with key stakeholders. Setting and sample: The setting was public sector hospital emergency departments located in metropolitan and regional Victoria, Australia. A convenience sample of eighteen emergency departments was recruited via the Victorian Department of Health. Participants: Survey participants were nurses and midwives who were employed at the study sites. Interview participants were a purposive sample of nurse unit managers and trainers. Methods: The Management of Aggression and Violence Attitude Scale was administered to training participants immediately before and 6–8 weeks after training. Semi-structured telephone interviews with trainers and managers occurred 8–10 weeks after the intervention. Results: Four hundred and seventy one participants completed the pre-test and post-test. Statistically significant shifts were observed in 5/23 items (Wilcoxon Signed Ranks Test: p≤0.01). Despite training, participants were undecided if it was possible to prevent patient aggression, and continued to be unsure about the use of physical restraint. Twenty-eight (82.3%) of managers’ and trainers’ eligible to be interviewed provided their perceptions of the impact of the program. Overall, these perceptions were consistent with the significant shifts observed in the survey items. Con

A key role of nursing staff in high secure hospitals is responding to patients' aggressive behaviour. Attitudes of staff in high secure hospitals may influence how they respond to patient aggression. Patients will have their own attitudes towards aggression and how it should be managed. In our study, the views of staff and patients regarding aggression were overall similar, with both groups espousing controlling means of aggression management (medication, restraint, seclusion) in addition to interpersonal strategies. Responding to aggressive behaviour is a key activity for nurses and other care staff in high secure hospitals. The attitudes and beliefs of staff regarding patient aggression will influence the management strategies they adopt. Patients will also hold attitudes regarding the causes of and best ways to respond to aggressive behaviour. This study measured the attitudes towards aggression of staff (n= 109) and patients (n= 27) in a high secure hospital in the UK using the Management of Aggression and Violence Attitude Scale (MAVAS). There was considerable concordance of views, staff and patients disagreeing on only two items on the MAVAS. Aggression was felt to have a range of causes, embracing factors internal to the person, factors in the external environment and situational or interactional factors. Interpersonal means of managing aggression were supported, but both staff and patients also advocated the use of controlling management strategies such as medication, seclusion and restraint. The implications of these findings for aggression management in high secure settings are discussed in the light of best practice guidelines that promote interpersonal approaches over controlling strategies.

Staff and relative perspectives on patient aggression in dementia care units are seriously under researched in the UK. We interviewed a number of nursing staff and relatives in four UK care homes in the North West of England. Using a combined approach of one-to-one interviews (for staff) and focus groups (for relatives) we explored their views as to the reasons for and ways of responding to aggressive behaviour. Using thematic analysis we found similar results from both staff and relatives and as such their views were categorized into two broad areas: causation and management. The results indicated that staff in the participating units embraced a person-centred approach to aggression management. They predominantly respond to aggressive incidents with interpersonal strategies, such as distraction as opposed to medication or restraint. Relatives were clear in their perceptions of aggression as an interpersonal challenge, which is compounded or mediated by the illness of dementia. Consequently they were positive in their views of staff using non-coercive interventions. Staff and relative perspectives on patient aggression in dementia care units are seriously under researched in the UK. Any work that has been conducted has relied upon quantitative studies. Qualitative research on aggression management in older peoples services are rare. In-depth views that can offer insights into causation and management strategies are therefore under represented in the literature. In order to investigate this issue further we interviewed a number of nursing staff and relatives in four UK care homes in the North West of England. Using a combined approach of one-to-one interviews (for staff) and focus groups (for relatives) we explored their views as to the reasons for and ways of responding to aggressive behaviour. This was part of a larger study reported upon elsewhere. Using thematic analysis we found similar results from both staff and relatives and as such their views were categoriz

ggression is reportedly common among older people with dementia in residential care. The attitudes of staff in care homes and strategies they use are under researched. Theoretical models that may be used to both understand and respond to such behaviour exist. They are the standard and person-centred paradigms. The aim of this study was to explore the views of nursing staff about aggressive behaviour in people with dementia and strategies used in practice. A survey of the attitudes of staff in six dementia care units using the Management of Aggression in People with Dementia Attitude Questionnaire was conducted including an audit of aggressive incidents using the Staff Observation Aggression Scale – Revised over a 3-month period. Staff expressed views reflective of a person-centred as opposed to standard paradigm. They viewed aggressive behaviour by people with dementia as deriving from the environment, situation or interactions with others. Participants strongly supported interpersonal means of responding to aggression, the moderate use of medication, and were largely opposed to physical restraint. Aggressive incidents were managed using less intrusive strategies such as distraction and de-escalation. Responses to aggressive behaviour, while pragmatic, were largely underpinned by a person-centred ethic as reflected in the attitudes expressed by staff.

Background: Staff from a range of health and social care professions report deficits in their knowledge and skills when providing end-of-life and palliative care, and education and training has been advocated at a range of levels. Aims: To review the literature related to classroom-based and distance learning education and training initiatives for health and social care staff in end-of-life and palliative care, in terms of their target audience, extent, modes of delivery, content and teaching and learning strategies, and to identify the most effective educational strategies for enhancing care. Design: A systematic review of the literature evaluating classroom-based and distance learning education and training courses for health and social care staff in end-of-life and palliative care. Data sources: Online databases CINAHL, MEDLINE, EMBASE and PSYCHINFO between January 2000 and July 2010. Studies were selected that discussed specific education and training initiatives and included pre-and post-test evaluation of participants’ learning. Results: 30 studies met eligibility criteria. The majority reported successful outcomes, though there were some exceptions. Level of prior experience and availability of practice reinforcement influenced learning. Participative and interactive learning strategies were predominantly used along with discussion of case scenarios. Multi-professional learning was infrequently reported and service user and carer input to curriculum development and delivery was reported in only one study. Conclusions: Classroom-based education and training is useful for enhancing professionals’ skills and perceived preparedness for delivering end-of-life care but should be reinforced by actual practice experience.

The administration of medication is an important therapeutic intervention. However, concerns have been raised about the management of this procedure in the acute area. Therefore, a survey was conducted with registered nurses (n = 24) and patients (n = 57) from three acute admission wards in an inner city hospital in the north west of England. Semistructured interviews were conducted immediately following medication administration and then analyzed using thematic analysis. Nurses' views were categorized into three themes: ward environment, communication, and sharing of information. Nurses reported that policies and procedures provided clear guidance, but that the task remained stressful and the role of other professionals affected the integrity of the procedure. Patients' views were categorized into four themes: effects and side-effects of medication, the process of administration, therapeutic relationships, and the sharing of information. Most patients were accepting of the administration of their medication, but called for improvements in information sharing and side-effect management. Information sharing is pivotal in establishing therapeutic relationships, but the time of administration might not be the most appropriate occasion for this.

Perhaps due to the complexities of the problem of aggression and violence, and to ethical issues relating to the mental health areas where much of the work is focused, it is the perspective of staff working in those areas that is most commonly sought in research studies. In contrast, tools to examine the patient’s view are rare. In this paper Joy Duxbury describes the piloting and development of a new tool, which aimed to survey the views of both patients and staff about the broader approaches used to manage patient aggression. This became the ‘Management of Aggression and Violence Attitude Scale’ (MAVAS), and the testing of this tool is the focus of this paper.