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Subjects:
Psychiatry
Introduction: Research on aggressive behaviors (ABs) in adolescent mental healthcare settings remains limited and underexplored. Such behaviors significantly affect staff, patients, and the therapeutic environment, necessitating nursing interventions for effective risk management to reduce their adverse impact on safety and quality of care. Objective: This review aimed to map the existing evidence on nursing interventions for the risk management of AB in adolescent mental health units. Methods: A search strategy was used to identify relevant studies in databases, respecting the Participant/Concept/Context (PCC) question formulation structure. This review covers studies describing nursing risk management strategies for adolescents (10 to 19 years old) with aggression problems and admitted to mental healthcare units. Results: From the 499 records initially identified, 9 articles met the inclusion criteria and were selected for review, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) and its associated flow diagram. The nursing interventions identified for managing AB in adolescent healthcare settings included risk assessment tools, targeted risk management strategies, evidence-based interventions but also various forms of coercive measures. Conclusions: This review integrates current knowledge on nursing interventions for the risk management of AB in adolescent mental health units. The focus of these interventions is prevention, by early intervention strategies but also intervention programs with improved outcomes for the patient, staff and therapeutic milieu, promoting less coercive interventions and increased care quality and safety.
- adolescent
- aggression
- mental health units
- interventions
- nursing
- review
Aggressive behavior (AB) in healthcare settings is referred to in the literature as a global health problem, assuming epidemic proportions [1,2,3], presenting clinical challenges but also attracting increasing research interest [4].
Psychiatric care, particularly in hospital units, is one of the most prevalent contexts and one in which most AB incidents are reported [5], being more evident in psychiatric healthcare units for children and adolescents [6,7].
Mental health problems in adolescence account for a substantial proportion of the overall disease burden at this stage of life and represent a leading cause of functional impairment. Evidence suggests that up to 50% of all mental disorders emerge before the age of 14, and approximately 20% of adolescents experience a diagnosable mental disorder before reaching 18 years of age [2,3].
This stage of life (adolescence) is defined as transition period from childhood to adulthood, comprehended between 10 and 19 years of age [8], and associated with the development of profound physiological, psychological, social and emotional changes [9], essential for the establishment of strong foundations that support good health in adulthood.
Although adolescence is commonly perceived as a generally healthy stage of human development, its transitional nature is associated with increased vulnerability [10]. This heightened susceptibility contributes to a well-documented rise in morbidity, particularly mental health disorders, as well as elevated mortality risk [8].
Despite the wide diversity of psychopathological clinical presentations in adolescence [11], self- or hetero-aggressive behaviors can be associated with behavioral, psychotic, bipolar, and eating disorders, or it may reflect an exaggerated response to challenging environmental circumstances [12].
These behaviors are the primary cause for referral and treatment in psychiatric emergency departments [13] and one of the main reasons for psychiatric hospitalization [14]. They pose a risk to patient safety, other patients, and healthcare professionals [15,16] affecting negatively the therapeutic milieu, disrupting established routines, and reducing the unit’s capacity to support recovery and rehabilitation [17]. In addition, AB contributes to increased financial burden through property damage and staff absenteeism [18,19].
The complexity of AB is evident in its very definition, as the scientific literature presents multiple conceptualizations [4,20]. These variations emerge not only from the multifaceted nature of human behavior but also from the influence of individual perceptions [21].
This review adopts a definition of AB that highlights the characteristic emotional development of adolescence, conceptualizing aggression as an adaptive response. Specifically, being defined as the use of physical or verbal force in reaction to perceived threats or experiences of frustration [13]. Verbal aggression is characterized by behaviors such as threats, shouting, the use of profanity, insults, and other forms of offensive language. Physical aggression, on the other hand, includes actions such as hitting, grabbing, punching, and swinging [22].
The etiology of AB is multifactorial, involving intrinsic (personal) and extrinsic risk factors (staff and ward climate) [22,23].
Intrinsic risk factors comprises prenatal or childhood aspects, such as maternal drug and alcohol as well as growth disorders or birth injuries [20]. Neuropsychological deficits, including impairments in self-regulation, inhibitory control, abstract reasoning, problem solving, sustained attention, and organization, have been identified as significant predictors of AB [20]. A negative family environment—characterized by low emotional support, unstable interpersonal relationships, domestic violence, parental abandonment, and experiences of physical or sexual abuse—has been described as an important trigger for AB [20]. Exposure to hostile and unsupportive school environment but also peer group effect can promote the emergence of AB, especially when the adolescent experienced bullying victimization. The use of alcohol and drugs have a positive association with AB [24,25].
Extrinsic factors are related to healthcare units, namely the ward’s social climate and staff attitudes [23]. Other risk factors such as prolonged hospitalization, same-gender inpatient composition, a younger patient population [26], lack of parental visits, or disruptions in the therapeutic environment, such as teasing another patient [27], are associated with an increased likelihood of AB in mental healthcare units.
Aggression episodes evoke fear among service users [28], adversely affecting the ward climate [29], and also induce clinical uncertainty in healthcare professionals [22].
Preventing AB should focus on enhancing the ward’s social climate [30], optimizing the physical environment, providing staff training, maintaining an adequate number of experienced personnel [31], and identifying service users at risk of AB [32] through the use of AB risk assessment screening tools [33] and the implementation of appropriate management strategies [34].
These preventive approaches but also management strategies for AB are evidenced by international entities such as the National Institute of Care Excellence (NICE) [23], World Health Organization [35] and others.
The main premise of AB prevention and management protocols is focused on a proactive approach that should be initiated at the earliest possible point within the patient’s behavioral deterioration [23]. This aims to decrease the risk, preserve patient autonomy and dignity while simultaneously ensuring a safe care environment for both healthcare professionals and patients [14,23], thereby positively influencing quality and safety of provided healthcare [36,37].
Despite key interventions such as medication, seclusion, and physical restraint being identified in the literature, they primarily address acute episodes rather than providing long-term management [15], creating a demand for evidence-based psychosocial interventions [21] and recovery-oriented [38] care that should be incorporated into comprehensive care plans throughout all stages of treatment.
On the other hand, the use of restrictive measures have been criticized for undermining self-determination and autonomy [39], as well as for lacking evidence to support their therapeutic effectiveness [40,41]. These measures also raise ethical considerations and debate should be considered [41,42].
Despite growing awareness, the prevention, management, and treatment of AB remain underexplored in nursing research [20], with limited studies investigating intervention programs or nursing strategies—highlighting an urgent need for effective approaches to address AB incidents [20,43].
Based on these premises, the decision to conduct a scoping review was aligned with its primary aim: to map the key concepts in a specific area of knowledge—namely, nursing interventions for managing the risk of AB in healthcare units for adolescents with mental illness. This review will provide an overview of the research conducted to date, highlight research gaps, and support the development of specific scientific studies, such as systematic reviews [44,45].
This entry is adapted from the peer-reviewed paper 10.3390/encyclopedia5030144
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