Staff training and physical intervention

STAFF TRAINING IN PHYSICAL INTERVENTIONS:

A SYSTEMATIC LITERATURE REVIEW

Andrew A McDonnell, BSc, MSc, PhD, Clinical Psychologist, Studio 3 training

Systems, 32 Gay Street Bath, BA1 2NT, UK

Amy Gould, BSc. Assistant Psychologist, Studio 3 Training Systems, 32 Gay Street,

Bath, BA1 2NT, UK.

Tamsin Adams, BSc. Research Assistant, Studio 3 Training Systems, 32 Gay Street,

Bath, BA1 2NT, UK.

Jodie Sallis, Assistant Psychologist, Studio 3 Training Systems, 32 Gay Street, Bath,

BA1 2NT, UK.

And

Regine Anker, Assistant Psychologist, Studio 3 Training Systems, 32 Gay Street,

Bath, BA1 2NT, UK.

Address for Correspondence: Dr Andrew McDonnell, 32 Gay Street, Bath UK, BA1,

2NT, UK. E-mail: Andy@studio3.org.

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Abstract

Physical restraint training is a billion dollar industry worldwide with hundreds of

companies providing almost as many different approaches to dealing with aggression in

care environments. Despite this there is an extremely limited evidence base for the

efficacy of such training and a systematic literature review of existing research has not

yet been conducted. This paper aims to review all published data on staff training

research which contained physical interventions, to highlight the most scientifically

rigorous of these papers and to make recommendations based on the findings.

Electronic literature searches were conducted using Web of Science ©, Cochrane

Database of Systematic Reviews © , Medline © , Social Science Citation Index © and

Psychlit © and from websites of leading international training organizations. Out of

60+ papers only fourteen studies were identified as experimental or quasi-experimental.

Studies showed evidence of effectiveness of training including decreases in client

incidents, reductions in restraint use, increased use of appropriate restraint, increases in

staff confidence, increased patient satisfaction and decreases in staff fear. Three studies

found no significant effects of training. Future research should (a) simplify course

content and use empirical methods to determine course content; (b) use multiple

reliable and valid outcome measures and adequate experimental designs; (c) make

greater use of behavioural skills training, including modelling, rehearsal and feedback

in live situations; and (d) evaluate follow-up and staff support mechanisms after initial

training.

Declaration of interests

The first author Andrew McDonnell is a Director of Studio3 Training Systems. Peter

Sturmey, Amy Gould and Tamsin Adams are employees of Studio3.

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INTRODUCTION

Physical restraint of a human being is a controversial and emotional experience for all

parties involved (McDonnell 2010) and should therefore be a last resort to dealing with

any form of challenging behaviour in care environments. However all too often

physical restraint has become the first choice (Deveau & McDonnell, 2008) and it is

painfully clear that abuse of such procedures occur in care environments across the

country (Winterbourne view in Bristol being the most recently publicised case). The

highly emotive and potentially fatal nature of physical restraint procedures means the

need for an evidence based approach is paramount. Despite this the literature is

relatively sparse. This paper aims to review all published data on staff training research

which contained physical interventions, to highlight the most scientifically rigorous of

these papers and to make recommendations based on the findings.

Physical interventions are described as “any methods of responding to challenging

behaviour which involves some degree of physical force to limit or restrict movement

or mobility” (Harris et al. 2000). The two most common categories are breakaway

skills and physical restraint. Breakaway skills can be defined as “physical strategies

which assists a person to break free of an aggressor, where actual physical contact has

taken place” (McDonnell, 2004). Physical restraint has been defined as “actions or

procedures which are designed to suppress movement or mobility” (Harris 1996, p100).

The application of physical restraint has inherent risks and there are many documented

cases of fatalities. David “Rock” Bennett died in 1998 whilst being restrained in a

prone position for 25 minutes on a psychiatric setting, restricting his ability to inhale

sufficient oxygen. (http://www.irr.org.uk/pdf/bennett_inquiry.pdf ). Gareth Myatt died

aged only 15 whilst being restrained in a Young Offenders establishment in 2004 after

being held by three adults resulting in him choking on his own vomit. Paterson et al

(2003) identified 12 here. Monitoring these deaths in the UK is not a straightforward

task. Sudden and premature deaths of people with intellectual disabilities have also

been related to poor health monitoring (Heslop et al., 2013). This is primarily because

the causes of death are not always clarified. In the US Norwod, Ciccome, Kennedy,

Moy, Allrich, Naiditch (2001) reviewed 61 restraint related deaths that occurred in

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North America. They reported that three quarters of those who died were male, 75%

had a psychiatric history but only 26% of these tragedies occurred in psychiatric

settings and that over one third of the deaths occurred to people over the age of 65.

Organisational culture and leadership is clearly an important variable in staff’s response

to violence (Deveau & McDonnell, 2008; Colton, 2004) and the message that

organisations are given will often be disseminated through policies and national

guidance and the medium of staff training \deveau & McGill XXXX( ) however

Deveau and McGill have identified gaps in policy and delivery of organisational

response to physical interventions. The effects of direct staff training per se may well

be limited (Deveau & McDonnell, in press). Evidence has demonstrated that the

monitoring of use of physical interventions by management can lead to reductions in

their use (Sturmey & Palen McGlynn, 2002) while there is limited evidence that

certain organisational cultures may actually increase service user vulnerability to abuse

(White, Holland, Marsland & Oakes, 2003). A recent study in the UK reported that

better service quality outcomes for people with a learning disability appeared to be

more commonplace in services with a more positive organisational culture (Gillett &

Stenfert-Kroese, 2003). Norway has recently implemented legal instruments regulating

the use of ‘coercive’ procedures for people with intellectual disabilities which have

reportedly led to considerable reductions in the use of restrictive interventions for

people with learning disabilities (Roed & Syse, 2002).

In the U.K. many staff would appear to be trained in a whole variety of training

programmes that involve the application of physical interventions. The evidence base

for these programmes would appear to be very limited (McDonnell, 2008., Stubbs,

Leadbetter, Paterson, Yorston, Knight & Davis, 2009., Allen, 2001). Goodness of fit of

training is also a clear component. Beech and Leather (2006) reviewed the literature

and illustrated this problem by maintaining that aggression management training is an

established health and safety response in most organisations. In contrast they also

acknowledged the limitations of such training: ‘Although aggression management

training is now widely available it is often inappropriate for the needs of different staff

groups.’ (pp. 41).

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Staff training is clearly not a panacea for reducing the use of restraint in care

environments; it should be viewed as necessary but not sufficient for change to occur

(Cullen, 1987). Despite this caveat there is a need to train staff in the frontline

appropriate strategies for managing violence and these should be have a good evidence

base. A recent Cochrane review examined issues of restraint in elderly care (Möhler et

al., 2011). There was insufficient evidence to endorse the effectiveness of educational

interventions aimed at preventing or reducing the use of physical restraints in geriatric

long-term care.

This review will examine the published literature to date in order to establish whether

there is an evidence base for staff training in physical intervention.

Literature search

The literature search was conducted using the Web of Science © search engine (1945 –

May 2013, The Cochrane Database © (2001-May 2013), Medline © (1966-May

2013) Social Science Citation Index © 1956-May 2013 and PsychINFO © (1967 – May

2013). The following keywords were used: aggression, violence training mental

retardation, learning disability, mental handicap, elderly, care staff, education,

psychiatry, mental health, disruptive behavior, psychiatric. Staff training was used as

the major keyword in all comparisons.

Websites of twelve training organizations approved to deliver training in UK services

for people with a learning disability (up until May 2013) were examined for evidence

of published research in staff training in physical interventions. All training papers

selected for the review had their reference sections examined in an attempt to discover

any articles that may have been missed in the electronic searches. This process

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produced no new studies.

Each paper was coded on twenty-two variables. Theses were participants and settings;

experimental design; training systems; duration of training courses; statistical analysis;

reliability of measures; outcomes; staff knowledge based measures; staff confidence

measures; the use of physical restraint; incident reporting; staff/service user injury data;

staff assault rate; staff sickness; acquisition of physical interventions; course content;

description of teaching methods; teaching methods; physical interventions, breakaway

skills; descriptions of physical restraint procedures.

A second person independently coded all of the papers. Inter-rater reliabilities for

specific categories were calculated by dividing the number of agreements by the

number of agreements plus the number of disagreements and multiplying by 100%. The

median inter-rater agreement was 100% (range 95.6-100%) for all coding categories.

Inclusion and exclusion criteria

The aim of the review was to identify empirical articles that had taught physical

intervention skills to staff in any broadly defined mental health service. Therefore

articles were included if: (1) they were published in a peer reviewed journal; (2) there

was evidence that staff training, rather than service audit had occurred; (3) physical

interventions were a component of the training and (4) the study utilized a control or a

comparison group to assess effect of training. Studies which only taught defusion skills

and unpublished articles were excluded. A total of eighty-four articles were excluded,

four because they did not appear in peer-reviewed journals (Bell & Mollison, 1995;

Bell & Stark, 1998; Brookes, 1988; Judd, 1996). Nineteen were excluded because they

contained no physical interventions training (Shah & De, 1998; Colenda, & Hamer,

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1991; Wondrak & Dolan, 1992; Corrigan, Holmes, Luchins, et al., 1995; Whittington

& Wykes, 1996; Nijman, Merckelbach & Campo, 1997; Moniz-Cook, Agar, et al,

1998; Arnetz, & Arnetz, 2000; Gentry, Iceton & Milne, 2001; Willetts & Leff, 2003;

Emmerson, Fawcett, Ward, et al 2007; Lipscomb, McPhaul, Rosen, et al 2006; Badger

& Mullan, 2004; Singh, Lancioni, Winton et al, 2006; Middleby-Clements & Grenyer,

2007). Four papers did not state that physical interventions were taught to their staff as

part of their programmes: (Mentes & Ferrario, 1989; Feldt & Ryden, 1992; Collins,

1994; Maxfield, Lewis & Cannon, 1996.) One paper was excluded because it focused

on non-physical post incident interventions to reduce violence (Flannery, Hansen,

Penket al., 1998) and two papers were excluded because they focused on staff training

in longer-term positive behaviour interventions (Berryman, Evans & Kalbag, 1994;

Grey, McClean, & Barnes-Holmes, 2002). Fifty-four were excluded as they did not

have a control or comparison group in their designs .

RESULTS

Fourteen articles were included in the final review. Table 1 reports the setting and

participants.

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Insert Table 1 about here

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Participants and settings

All studies took place in services for various kinds of adults. Nine were in adult

psychiatric settings (2, 3, 5, 7, 8, 9, 10, 11, 13), two took place in services for adults

with learning disabilities (1, 14), one took place in older adults services (12) and one

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took place in services for adults with an autistic spectrum disorder (6). One (22) took

place with a non-specified population. The studies took place in the USA (6 studies),

Switzerland (3 studies), United Kingdom (2 studies), Canada (1), Australia (1) and

Norway (1).

Experimental design

All studies used quasi-experimental designs which included control or comparison

groups

Training Systems

One study involved the control and restraint system (8). One study reported data using

the CPI system (11), one employed The Welsh Method (1) and one used Studio3

training (6). Two used an Aggression Management Training Programme (3, 9). Five

studies reported individual studies on a range of training systems including:

‘Aggression Control Techniques (ACT) (5)’, ‘The Management of Assaultive

Behaviour’ (2), ‘Safe Physical Restraint’ (7), ‘Therapeutics for Aggression’ (13) and

‘Emergency Procedures’ (14). Three studies did not specify what training they used (4,

10, 12).

Duration

The duration of the training courses ranged from less than one day to more than five

days. Three were less than a full day (4, 10, 14), three specified one day workshops (7,

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12, 13), one specified two days, (2), two specified three days (5, 6), four specified five

days or greater (3, 8, 9, 11), one training course specified either two to three days

depending on need (1). One course only offered four hours for training (4).

Statistical Analysis

One paper reported descriptive statistics only (14), six studies solely used parametric

statistics (2, 4, 6, 10, 11, 13), six studies used non -parametric statistics only (1, 3, 5, 7,

9, 12) and one study used a combination of statistical analyses (8).

Reliability of measures

Eleven studies reported reliability data for at least their main dependent measures (1, 2,

3, 6, 7, 8, 9, 10, 11, 13, 14). Three studies reported no reliability data for their main

dependent measures (4, 5, 12,).

Reported outcomes

There were eight types of outcomes reported: increases in knowledge, staff confidence,

use of physical restraint, incident reporting, staff/service user injury, staff assault rate,

skill acquisition, and staff sickness.

Staff knowledge based measures. Two studies reported increases in staff

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knowledge using a variety of questionnaire measures (1, 4,) although only one study

reported reliability data for these measures (1). One study reported no significant

increases in knowledge based measures post training (4), but, no reliability data was

reported for either of these measures.

One study (11) used a patient restraint written test with high inter rater reliability, but

reported no test retest reliability measures or other measures of psychometric

robustness. One study (8) used a 12-item tolerance of behaviour scale but no reliability

data was reported for this measure. One study reported positive course feedback at 15-

month follow up (11).

Staff confidence. Five studies reported increases in staff confidence (1, 6, 7, 8,

13) four of which used measures with acceptable reliability ratings (1, 6, 7, 13). One

study maintained the increase in post training confidence ratings at a 15-month follow

up (13). Two studies reported no increases post-training in confidence (3, 4) however

one study (3) reported reliability data while the other did not (4).

Use of physical restraint. Two studies reported reductions in the use of

physical restraint (1, 12).

Staff/service user injuries. No studies reported staff injuries during training

courses. One study reported reductions in staff injuries following training (2)

Staff assault rate. Two studies reported reductions in rates of assault on trained

versus untrained staff after training (5, 10). One study reported increases in assault rate

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post training (11).

Staff sickness. One study reported reduction in sickness rates relating to

aggression after training (11).

Acquisition of physical interventions. Two studies reported acquisition of

physical interventions on training courses (10, 14). A US study conducted in a learning

disability setting (14) reported data using unannounced assessments of physical skills

competency in the workplace. Uniquely, this study used behavioral skills training,

consisting of instructions, modeling, rehearsal and feedback to mastery criterion, and

pyramidal training of trainers to teach physical interventions. This resulted in staff

acquisition of restraint skills.

Course content

Defusion strategies, here defined as non-physical methods such as distraction and

redirection, which focused on deescalating an incident, were taught on eleven training

courses (1, 2, 4, 5, 6, 7, 8, 9, 10, 11, 13) and three studies were either unclear about

defusion skills or did not mention them at all (3, 12, 14). No studies reported a clear

theoretical model for their use of defusion strategies.

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Teaching Methods

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Table 2 describes the teaching methods used in the fourteen training courses.

Nine of the training studies reported using lecture or classroom based formats (1, 2, 3,

6, 7, 8, 10, 11, 12). One study reported using group work/discussions (13). One study

referred to ‘hands on training’, but no further detail was provided (3). One training

course reported using audiovisual aides (11). One paper used behavioural skills

training (14) and ten studies reported using role play (1, 5, 6, 7, 8, 9, 10, 11, 13, 14).

Physical interventions

Table 2 describes the physical interventions taught on training courses. Eight studies

did not provide a specific list of the physical interventions taught on training courses (2,

3, 7, 8, 9, 11, 12, 13). Four studies referred to other source materials to describe their

physical interventions (1, 6, 8, 9).

Breakaway skills

The term ‘breakaway skills’ describes physical intervention’s that enable staff to escape

or disengage from a person, such as removing one’s arm from a client’s grasp. Three

studies used the term ‘breakaway skills’ (3, 4, 9). Two studies used the term ‘control

and restraint’ to describe their training (8, 9). These studies of break away skills and

C& R did not operationalize these terms. Four studies provided topographical

descriptions of the breakaway skills taught to staff (4, 5, 10, 14). Two studies described

physical interventions operationally so that they could be independently replicated (10,

14).

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Three studies reported teaching disengagement strategies from hair pulling (4, 5, 6).

Three reported physical disengagement techniques for escaping from

choking/strangulation (4, 6, 10). Four types of physical techniques categories appeared

in five studies: punching (5, 10, 14), wrist grabs (4, 6), biting (4, 6) and one study

reported teaching defences against kicking (5). Unusual techniques included defences

from headlocks (5). The topographies described above may be similar, however, there

is no way to discern the physical techniques taught on these training courses from the

published articles.

Descriptions of Physical Restraint Procedures

Physical restraint techniques were difficult to discern from the majority of articles in

the review. No detailed descriptions could be compiled from the published articles to

describe the physical restraint methods employed on training courses. One study did

report using a chair restraint method, which was operationalized (6).

DISCUSSION

The purpose of this literature review was to examine the outcomes of staff training in

physical intervention. Despite being a multi-million pound industry, a systematic

review of staff training in care environments has never been carried out. Ninety eight

papers were identified as relevant but only 14 utilised some form of control or

comparison group. This would be a damning statistic in any field of applied research.

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This review raises a number of subtle measurement issues around the evaluation of

staff training courses in physical intervention. In reality most staff training consists of

a combination of educational elements rather than one specific entity. Descriptions of

training courses were often not explicit.or clear. The methods of delivery (role play,

didactic in their goals and aims ranged widely and included increasing staff skill,

knowledge, and confidence and reducing staff fear, reducing the use of physical

intervention, increasing the use of appropriate forms of interventions, reducing assault

rates, reducing service user and staff injuries and associated costs and reducing staff use

of sick days. Each of these aims implies difference measures, as well as the use of

multiple measures. Thus, a course which results in acquisition of staff skills and

reduction in client incidents may still not be judged adequate if it also results in

increases in staff and service user injuries, staff turn over and associated costs.

Likewise, a course that does not impact client incidents may still have benefits, such as

reduced staff injuries associated with increased use of appropriate safe forms of

restraint. No studies addressed the issue of the validity of measures and the importance

of going beyond statistical significance to address clinical and educational significance.

Explicit rationales for staff training should guide the choice of outcome measures. The

use of more intrusive interventions that involve the application of joint locks may

function as positive punishment, then their contingent application should result in

reduced frequency of service user incidents toward staff. Staff training methods should

include empirically validated methods, such as minimizing verbal methods of staff

training and focusing on behavioural skills training. Some training courses were

effective in teaching skills to staff, however, there was an absence of follow-up. Future

research could begin to evaluate feedback systems and problem solving protocols as

adjuncts to initial staff training.

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Many courses did not clearly operationalize the knowledge and skills taught to staff.

Few papers operationally described the physical disengagement (breakaway) skills and

restraint procedures in sufficient detail. However, two papers did provide task analyses

of restraint procedures (10, 14). These papers can be used as models for future work.

Future developments should use both task analyses and video models of restraint

methods in order to ensure that the physical interventions procedures are accurately

specified. A related observation is that courses did not specify clear minimum

knowledge and skill criteria to pass the courses. Future research should develop such

criteria. Courses used a wide range of teaching methods including lectures, discussion

and classroom based verbal formats, video-modelling and role play. No courses used

practice with clients in actual service settings. These methods may be effective in

giving staff knowledge and improving staff confidence. However, there is no data

demonstrating that these methods are effective in leading to accurate use of skills in the

workplace with clients.

Behavioural skills training, consisting of instructions, modelling, rehearsal and

feedback to mastery criterion, is a promising approach (Sturmey, 1999). It has been

successful in teaching many skills to staff and family members in a wide range of

populations and settings (Seaman, Greene, & Watson-Perczel, 1986; Sturmey, 1999) as

well as restraint skills (14). However, courses should be supplemented with behavioural

skills training in actual work place settings and should include sufficient exemplars to

promote generalization of staff skills to novel unstrained situations and clients (Stokes

& Baer, 1977.) Surprisingly, no studies reported data on skill retention after training.

Evidence from other fields would indicate the importance of this variable. There is a

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literature in Cardio Pulmonary Resuscitation which does demonstrate deterioration in

skills over time, especially where individuals have not practiced the skill in situ. Future

research should also address this issue (Anderson, Gaetz, Statz & Kin, 2012). It is

possible that in many cases staff who are trained in physical interventions will struggle

to recall them in situ.

Courses also varied widely in the number of physical intervention methods taught. For

example, Phillips and Rudestam (10) taught only two physical intervention methods

and Hurlebaus and Link (4) taught at least six physical interventions in a 1 hour

session. It seems unlikely that staff can acquire skills in the large number of

intervention procedures that some courses attempt to teach in a short period of time

available. Future research should use data based methods, such as observations of the

frequency with which intervention methods are used as a basis for simplifying the

number of skills taught to mastery criteria. Other less frequently used, but potentially

important interventions methods should be taught on an as needs basis in service

settings as the need arises (BILD, 2001.)

Future empirical research should identify the training needs that are common across

many populations and settings, those that are specific to certain populations and

settings and use these data to guide the content of training courses. It is also important

that the effectiveness and acceptability of these different methods are evaluated.

Another approach to determine the content of training is to offer a menu of course

content and for trainees and organization to select those aspects they feel is most

relevant.

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Several papers had important strengths that could be models for future research. As

mentioned above one paper used tasks analyses and videotaped models of the

intervention procedures used (14). Van den Pol et al. (14) used behavioral skills

training both to train staff to implement restraint procedures, taught other staff to use

behavioural skills training to train other staff and used unannounced observations in the

work place to observe implementation. Several experimental evaluations of courses had

strengths. For example, Rice et al (11) used multiple dependent variables, reported

reliability data and used a control group and one-year follow up. Philips and

Rudestam’s (10) experimental study was notable because they used role play and

rehearsal and rated staff behaviour and fear.

There is now a body of research reporting the effectiveness of a wide range of courses

to manage aggressive behaviour in a variety of populations and settings. These studies

indicate that staff training may be effective, but not on all occasions. Future research

should address the following areas. First, the courses should be explicit in their aims

and use this to guide empirically identifying content of training. Second, they should

simplify and limit the content of courses to focus on those areas that most important to

the audience and to spend sufficient time to teach critical skills effectively to

participants. Third, evaluation should use experimental designs and address

measurement issues such as reliability, validity and the use of multiple outcome

measures as well as follow-up, implementation, generalization and maintenance of

skills after training in the workplace. The selection of measurements should be driven

by some rationale for the mechanisms that may underlie staff training. For example, if

redirection and defusion skills are key mechanisms in reducing client incidents and the

use of restraint, then data should show that staff use these skills more frequently after

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training leading to fewer client incidents and less frequent physical interventions.

Alternatively, if the rationale for the use of physical interventions is that they safely

reduce injuries to other service users and staff, then the data might show no change in

service used incidents, but a decrease in service user and staff injuries.

The evaluation of staff training is a complex process. Our initial literature search found

98 studies on staff training that dealt with aggression in care environments. Despite

these studies forming the empirical basis for a worldwide training industry that deals

with millions of vulnerable and oftentimes highly distressed individuals only 14 used

any form of recognised control design. There is undoubtedly a need for a series of

randomised controlled trial studies. Future research needs to utilise more robust

scientific design incorporating control or comparison groups if we are to identify the

most successful elements of staff training.

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29

Table 1. A table of the design and settings, course duration and title, description of

reliability measures and outcome data for 52 staff training studies on physical

interventions.

Author Design and

Setting (inc.

control /

comparison

group and

statistics)

Duration of

course and

Title

Description

and

Reliability of

Measures

Outcome Data

1. Allen & Tynan

(2000).

Quasi-

experimental

design (between

subjects element:

trained versus

untrained staff;

within subjects

element:

untrained group,

which then

received

training). n=109,

51 exposed to

training, 58 not

exposed in UK –

in community

services with

people with

learning

disabilities.

Non-parametric

statistics used.

Preventing

and

Responding

to Aggressive

Behaviour

(The Welsh

Method) 2 to

3 day course

(1 day theory,

1-2 day

physical

interventions)

10 item

confidence

measure

(Thackrey,

1987),

(Cronbach’s

Alpha= .88)

A 20 item

reactive

strategy

questionnaire

(Cronbach’s

Alpha = .64)

Trained group was

significantly more

confident than

untrained group.

Trained group

scored higher on

reactive strategy

questionnaire.

Both measures

statistically

increased when

untrained group

received training.

2. Carmel & Hunter

(1990)

Quasi

experimental

design

comparing staff

who had received

training in

managing

assaultive

behaviour (N

=392) with staff

16-hour

training

course

California

Dept. of

Mental Health

Training in

the

Management

of Assaultive

Examined

staff injury

data and rates

of patient

aggression. No

reliability data

provided for

either

measure.

Staff who received

aggression

management

training reported

lower rates of

injury. No

relationship

between CPR

training and staff

injury.

30

who received

training in CPR

(N =602). Study

took place in a

973-bedded

forensic hospital

in the USA.

Parametric

statistics used.

behaviour.

3. Hahn, Needham,

Abserhalden et al

(2006)

Quasi-

experimental

pre/post design.

Mental health

setting (N=63

mental health

nurses inc.

control group; n=

34 mental health

nurses). Acute

psychiatric ward

setting in

Switzerland.

5-day

aggression

management

training

programme

developed in

the

Netherlands

(Oud 1997).

The

programme

consisted of

24 lessons

lasting 50

minutes.

Management

of Aggression

and Violence

Attitude Scale

(MAVAS)

(Duxbury,

2002). Good

stability

(Pearsons r =

0.89) and

construct

validity

reported.

Reported

Cronbach

alphas for the

four subscales

of the

MAVAS:

0.54, 0.41,

0.25, and 0.71

respectively

(Duxbury,

2002).

No significant

attitude change in

the intervention

group compared

with the control

group at post-test.

4. Hurlebaus & Link

(1997)

A pre-post

design with a

control group.

Total N= 32

nurses based at

an inner city

teaching hospital

in the USA, A

training group

(N= 22), and a

control group

that did not

receive training

(n= 10).

Parametric

statistics used.

A 4-hour

training

course, 1 hour

devoted to

physical skills

– title of

course

unspecified.

15-item

knowledge

test (which

consisted of

10 multiple

choice and 5

true/false

questions) –

no reliability

data provided.

Two visual

analogue

scales used to

measure safety

and

confidence (no

reliability

No significant

differences found

in measures of

safety, confidence

or knowledge in

the study.

Inappropriate

statistical analysis

makes this paper

difficult to

interpret.

31

data)

5. Infantino & Musingo

(1985)

Quasi-

experimental

design,

examining a

trained (N = 31)

versus untrained

(N = 65) group

of staff in a

psychiatrics

hospital in the

USA with a

follow-up

between 9 and 24

months after

training. Non-

parametric

statistics used.

Three-day

training

course using

Aggression

Control

Techniques

(ACT).

Examined

rates of staff

assaults,

injuries and

days lost from

work. No

reliability data

reported.

Only one trained

staff was assaulted

with no injury,

37% of the

untrained staff

were assaulted,

79% of these

resulted in

injuries. Staff

injuries were

reported for the

untrained staff.

6. McDonnell,

Sturmey,

Oliver, et al

(2007)

Quasi-

experimental

design (between

subject element

trained N = 43

comparison

group previously

received training

N = 47.Pre – post

test 10 month

interval. Services

for people with

autism spectrum

disorders.

Analysis of

within subject

pretest scores – t-

test. 5 dependent

measures

analysed through

MANCOVA

with

experimental

group as between

subject factor

and pre-training

as covariate

factor. Each

dependent

variable analysed

using separate

ANCOVA.

Studio 3 – 3

day course

half

theoretical

half practical.

The ‘Staff

support and

satisfaction

questionnaire’

(3SQ) Harris

& Rose (2002)

good test-

retest

reliability

(r=0.82), high

levels internal

reliability

(Cronbachs

alpha = 0.92).

The

‘Shortened

ways of

coping scale’

Hatton &

Emerson

(1995) good

reliability and

internal

consistency

(average

Cronbachs

alpha = 0.76).

The ‘Thoughts

about

challenging

behaviour

questionnaire

Staff training

showed increases

in staff confidence

but not other

measures of staff

belief, support,

coping or

perceived control.

No evidence of

reduction in client

challenging

behaviour.

32

Dagnan

(2007) very

high internal

consistency

(alpha = 0.85).

The

‘Challenging

behaviour

confidence

scale’

McDonnell

(1997) good

internal

consistency

(Cronbachs

alpha = 0.95).

The ‘Checklist

of challenging

behaviour’

Harris,

Humphreys, &

Thompson,

1994).

Relationship

between

measures

investigated

using

Pearson’s

product

moment

correlations

showed

approaching

significance

for 3SQ and

thoughts about

behaviour,

other

correlations all

non-

significant

therefore

measures not

inter-

correlated.

7. McGowan,

Wynaden,

Harding et al

(1999)

Quasi-

experimental

design with 6-

month follow-up,

7-½ hour

module in

“Safe

physical

Thackrey

(1987) 10-

item

Confidence

Trained group (N

= 42) had higher

confidence scores,

than untrained

33

compared trained

staff at a

psychiatric

hospital (N = 42)

with untrained

staff in a secure

facility (N = 15),

who later

received training

in Australia.

Non-parametric

statistics used.

restraint”. Scale – no

reliability data

provided.

group (N =15) –

these significantly

increased after

training.

8. Needham,

Abderhalden,

Zeller, et al.

(2005)

Pre-post design

with control

group. Nursing

staff (N =117)

received training

compared with

control group of

staff (N =60)

who did not

receive training

in Switzerland.

Non-parametric

and parametric

statistics used.

Training

consisted of

4 days 20 x

50 minute

lessons.

“Curriculum

Corresponds

approximately

to control and

restraint

training”

10-item

confidence

scale

(Thackrey,

1987)

(Cronbach’s

Alpha = .92),

Shortened

Version of

Perception of

Aggression

Scale (POAS

– S)

(Reliability

sited in earlier

paper), two

vision

analogue

scales (no

reliability

data)

Significant

increases in

confidence post

training.

Experimental

group increase in

scores in one

visual analogue

scale

(comprehensible /

purposeful). No

significant

difference in

POAS - S.

9. Needham,

Abderhalden,

Halfens et al.

(2005)

Randomised

control trial of 87

acute psychiatric

wards in

Switzerland. 3

wards of staff (N

= 30), 3 wards

acted as a control

group (N = 28).

Non-parametric

statistics used.

Consisted of 5

day training

programme

consisting of

20 x 50

minute

lessons.

Management

of Aggression

(Oud, 1997).

Perception of

Aggression

Scale (POAS

– S) 12-item

tolerance scale

– no reliability

data, and the

impact of

patient

aggression on

carer scale

(IMPACS) –

(Cronbach

Alpha’s = .78)

No effect of

measures pre and

post training.

10. Phillips &

Rudestam

(1995)

Between-subjects

pre-post design,

2-week follow-

Untitled

training

programme 4

Hostility

inventory (no

reliability

Judges ratings of

fear in role-plays

lowest for the

34

up (N = 14). 3

groups (N = 24)

didactic training

(N = 8), didactic

plus physical

skills training (N

= 8), no training

control group (N

= 8). Psychiatric

staff in two state

hospitals in the

USA

participated.

Parametric

statistics used.

hours 20

minutes

data),

videotapes of

physical

competence

and ratings of

behaviour

expressed

aggression and

fear (high

inter-rater

reliability

ranging from

0.94 - 0.97)

didactic and

physical

intervention group.

Physical

competency rated

as highest for this

group. Inverse

relationship

between judges’

ratings of physical

competence and

observed fear.

Follow-up

interviews

indicated that staff

in the trained

group of didactic

and physical

intervention skills

reported 23%

fewer incidents.

Authors claimed

that participants

with lower levels

of physical

competence

demonstrated

significantly lower

role-play

performances.

Participants in the

didactic only and

control groups

appeared unable to

maintain a safe

distance between

themselves and an

attacker compared

to the didactic

training and

physical

interventions

group.

11. Rice, Helzel,

Varney et al

(1985)

Between-subjects

pre-post design

with a 15-month

follow-up (N =

63) staff.

Training

provided for

Five-day

training

course in

crisis

prevention

and

intervention

Assault rates

(inter-rater

reliability 69%

- 100%),

assault rates

leading to

days off work

Increases in

performance in all

pre-post

simulations and

written tests.

Significant

reduction in

35

mental health

staff (N = 126)

and staff in a

maximum-

security unit (N

= 89) and

compared with a

control group of

staff (N = 37) in

Canada.

Parametric

statistics used.

(CPI). (inter-rater

reliability

88%), A

sensitive

situations

skills test

(inter-rater

reliability

ranged from

81% - 100%),

audio-taped

role-play

scenarios

(inter-rater

reliability of

99% and

90%), physical

skills test

(inter-rater

reliability

98%), self

defence and

patient

restraint

written tests

(inter-rater

reliability

100%), job

reaction scale

(items -

unspecified)

(Cronbach’s

Alpha = 0.71

– 0.76)

workdays lost due

to patient violence.

Assault rates

increased post

training. Course

feedback from

course participants

remained positive

at 15-month

follow-up.

12. Testad,

Aasland &

Aarsland

(2005)

Quasi-

experimental

pre-post design,

data collected

immediately

before and after

the training had

taken place,

looking at the

effect of staff

training on the

use of restraint in

dementia in four

nursing homes in

Stavanger,

Norway, with a

Intervention

consisted of a

6 hour

seminar

focusing on

dementia,

aggression,

problem

behaviour,

decision

making

process and

alternatives

towards the

use of

restraint. Each

Demographic

and clinical

information

was collected

by

interviewing

the seniors.

Severity of

dementia was

assessed using

the Clinical

Dementia

Rating (CDR).

Outcome

measures were

the Brief

At baseline the

number of

restraints and

BARS scores did

not differ,

however on follow

up the use of

restraint was

significantly lower

in the intervention

group compared to

the control group.

Reducing the

number of restraint

by 54%.

36

control group (N

= not specified)

and an

intervention

group (N =not

specified).

Non-parametric

statistics used.

group was

then given

guidance for

one hour

every month,

for 7 months.

Agitation

Rating Scale

(BARS) and

the frequency

of restraint

assessed by a

standardised

interview. No

reliability data

provided.

13. Thackrey

(1987)

Between subjects

design

comparing a

trained (N= 68)

versus an

untrained (N =

57) group at 3

time periods –

pre, post and 18-

month follow-up.

Training took

place in a

community

mental health

centre, a state

psychiatric

prison, and a

state psychiatric

hospital in the

USA.

Parametric

statistics used.

An 8-hour

programme

presented in 2

x 4-hour

sessions one

week apart

entitled

“Therapeutics

for

Aggression”.

A 10-item

confidence in

coping with

patient’s

aggression

(Cronbach’s

Alpha = .92)

Trained group

showed post

training increases

in confidence

which did not

decrease

significantly post

training follow-up.

The untrained

group showed no

significant

changes under the

three time periods.

14. Van Den Pol,

Reed & Fuqua

(1983)

Multiple baseline

design.

examining three

safety related

skills (fire safety,

emergency

procedures after

a person has had

a seizure and

physical self

defence). Study

took place in an

87-bedded

residential

service for

people with a

learning

disability in the

3x 30 minute

workshops in

Emergency

Procedures.

Role-play

assessments of

self defence

procedures

rated by 2

independent

raters (average

inter-rater

reliability

90%).

Assessments

took place on

an

unannounced

basis. 5-item

self-report

questionnaire

(no

Trainers

demonstrated

competency levels

post training in

‘self defence’

skills. Control

trainees showed no

increase in any

skill acquisition.

None of the

trainee staff were

still employed at

follow-up. One

trainee reported

using physical

intervention in the

work place.

37

USA. Total N =

13. 4 trainees, 3

maintenance

condition

trainees, 4

trainers, and 2

control trainees.

23-month

follow-up of staff

who had received

training

(telephone

interviews).

Descriptive

statistics

reported.

reliability),

telephone

follow-up of

(N = not

specified)

38

Table 2. A table of course content, description of physical interventions and

description of teaching methods for 52 staff training studies on physical interventions.

Author Course

Content

Description of

Physical

Interventions

Description of

Teaching

Methods

1. Allen, McDonald,

Dunnet al (1997)

Understanding

aggressive

incidents,

primary

prevention,

secondary

prevention,

reactive

strategies – inc.

physical

interventions

and post

incident

support for

clients and care

givers.

Unclear in article,

referred to

unpublished training

manual – Doyle,

Dunn, Allen and

Hadley (1996).

Classroom

instruction,

role play and

repeated

practice of

physical

interventions

2. Carmel & Hunter

(1990)

16 hour training

course which

included:

Attention to

inter-personal

skills and the

management of

violent patients.

None specified Didactic and

lecture based

format and

practical

instruction to

the

management

of violent

patients

described.

3. Hahn, Needham,

Abserhalden et al

(2006)

The programme

covered the

following areas:

definitions of

aggression,

violence and

sexual

intimidation;

nature and

prevalence of

Breakaway

techniques.

Problem-based

learning,

mixture of

theoretical

elements,

exchange of

experience and

hands-on

training.

39

aggression;

theories of

aggression;

nursing care

plans; nursing

interventions

(predication,

prevention,

communication,

breakaway

techniques,

boundary

setting, and the

use of measures

to limit

patients’

freedom); post-

incident care;

the ethics of

aggression

management;

ward security.

4. Hurlebaus & Link

(1997)

Aggression,

crime, verbal

and non-verbal

signs of

agitation,

identification of

antecedent

signs of

aggression, use

of body

language, tone

of voice and

eye contact.

Self-defence

techniques,

breakaway from wrist

grabs, chokes (front

and rear), hair pulling,

blocking kicks, “how

to release from a bite”

Handouts,

group

discussions,

demonstration

of physical

techniques.

5. Infantino &

Musingo (1985)

3 training

phases over 3

days –

1) Policies and

procedures and

verbal

strategies

2) Physical

interventions

designed to

provide staff

with “release

and de-

escalation

skills”

Yes –limited

description of getting

free from hair pulling,

choking, head locks,

blocking punches and

kicks. Restraint

methods not

described.

Case vignettes,

role-play,

video tapes are

used to

demonstrate

are described

the physical

skills taught.

40

3) Physical

restraint and

incident

reporting

procedures

6. McDonnell,

Sturmey, Oliver, et

al (2007)

Does McDonnell, Waters, &

Jones (2002). In D. Allen (Ed.)

Low Arousal Approaches in the

management of challenging

behaviour. Training carers in

physical interventions.

Research towards evidence

based practice (pp.104-113).

Kidderminster:BILD have any

PI training inc and should it be

inc?

A day and a

half theoretical

including legal

issues, causes

of aggressive

behaviour, staff

support and low

arousal

approaches.

Day and a half

high frequency

behaviours inc

hair pulling,

biting,

grabbing,

airway

protection, two

person client

chair restraint

in upright

posture.

High frequency

behaviours inc hair

pulling, biting,

grabbing, airway

protection, two person

client chair restraint

in upright posture.

Course content and

format refered to in

McDonnell et al.

(1998), McDonnell et

al. (1991a, 1991b,

1991c, 1993)

Lectures,

modelling of

methods,

rehearsal using

role play.

7. McGowan,

Wynaden, Harding

et al. (1999)

8 ½ hr one day

module in “safe

physical

restraint”.

Including early

recognition and

management of

antecedent

behaviours,

defusion skills,

debriefing,

team work and

role assignment

during the

restraint

process.

Not specified Role play

scenarios,

lecture based

methods

implied but

not clearly

specified in

paper.

8. Needham,

Abderhalden, Zeller

et al. (2005)

Training

program

consisting of 20

x 50 minute

lessons in:

Caution and

Genesis of

aggression;

Breakaway

techniques, physical

restraint not

described.

Lecture based

and role play.

41

theories on the

various stages

of aggressive

incidents;

behaviours

during

aggressive

situations;

reflection on

one zone

aggressive

components;

types of

conflict

management;

communication

and interaction;

post aggression

procedures;

work place

safety;

prevention of

aggression.

9. Needham,

Abderhalden,

Halfens, et al.

(2005)

Training

program

consisting of 20

x 50 minute

lessons in:

Caution and

Genesis of

aggression;

theories on the

various stages

of aggressive

incidents;

behaviours

during

aggressive

situations;

reflection on

one zone

aggressive

components;

types of

conflict

management;

communication

and interaction;

post aggression

procedures;

Breakaway

techniques, physical

restraint not

described.

Lecture based

and role play

42

work place

safety;

prevention of

aggression;

breakaway

techniques.

10. Phillips & Rudestam

(1995)

Didactic

material

includes:

Theories of

learning,

dynamics of

violence,

warning signs

of violence,

non-verbal

communication,

intervention

strategies and

legal issues.

Yes – specific

physical interventions

described in a non-

visual manner in the

article. Physical skill

– “a repel and push

off to invasion skill

was taught as a

defence to a frontal

choking attack”. A

posture to block

attacks calle ‘the

repel’. Clear

descriptions of both

techniques.

Role play and

lecture format

11. Rice, Helzel, Varney

et al (1985)

Recognition of

behavioural

cues; verbal

techniques to

be used with

highly upset

individuals;

“self defence

techniques”;

Physical

restraints; post

incident

responses

Not clearly specified

in paper – “self

defence techniques” –

no indication of

number of techniques

taught with regard to

patient restraint.

Lecture based

including live

simulation of

crisis (role

play); audio

visual

materials.

12. Testad, Aasland &

Aarsland (2005)

A six hour

seminar

focusing on

dementia,

aggression,

problem

behaviour,

decision

making

processes, and

alternatives to

restraint. A

manual for the

seminar was

developed to

make sure that

Not clearly specified

in paper

Seminars.

43

all groups were

provided with

the same

information.

Each group was

then given

guidance for

one hour every

month, for 7

months.

13. Thackrey (1987)

Legal, ethical

issues,

psychological

intervention

and assessment

techniques,

team work,

communication

skills and

physical

methods for

“non-abusive

self protection”

Not specified Didactic

lectures,

selected

readings,

group

discussions,

experiential

exercises,

modelling /

simulation /

role-play and

practice of

physical

manoeuvres.

14. Van Den Pol, Reed

& Fuqua (1983)

3x 30 minute

workshops.

Staff taught

how to train

new staff. In

addition staff

taught how to

conduct the

emergency

procedure.

Yes – blocking

punches; blocking

kicks; releasing

clothing grab; using a

‘thumb pry’; release

of a body part grab;

using a chair for

protection.

Workshop

format used

with modelling

procedures and

role play.