Journal of Psychiatric and Mental Health Nursing, 2013, 20, 396404

The influence of staff training on the violence

prevention and management climate in psychiatric
inpatient units
jpm_1930

396..404

A. BJRKDAHL1 phd rmn, G. HANSEBO3 rnt phd &

T. P A L M S T I E R N A 2 p h d m d
1

Senior Nurse Consultant, Division of Psychiatry, 2Assistant Professor, Social and Forensic Psychiatry Program,
Division of Psychiatry, Department of Clinical Neuroscience, Karolinska Institutet, and 3Head of department of
Health Caring Sciences, Ersta Skndal University College, Stockholm, Sweden

Keywords: inpatient, management, pre-

Accessible summary

vention, staff training, violence, ward

climate

Correspondence:
A. Bjrkdahl

SLSO
Box 179 14
SE-118 95 Stockholm
Sweden
E-mail: anna.bjorkdahl@sll.se
Accepted for publication: 13 April 2012
doi: 10.1111/j.1365-2850.2012.01930.x

Violence prevention and management is an important part of inpatient psychiatric

nursing because both patients and staff need to feel safe and secure.
The Bergen model is a violence prevention and management staff-training programme that is based on the three essential staff factors of the City model: positive
appreciation of patients, emotional regulation and effective structure.
Based on the City model, we developed a 13-item questionnaire in order to find out
how patients and staff rated the violence prevention and management climate on
psychiatric wards where the staff was trained according to the Bergen model
compared with wards where the staff was not trained.
The result showed that the staff on trained wards had a more positive perception of
the violence prevention and management climate on four of the items and the
patients on one item.

Abstract
Violence prevention and management is an important part of inpatient psychiatric
nursing and specific staff training is regarded essential. The training should be based on
primary, secondary and tertiary prevention. In Stockholm, Sweden, the Bergen model
is a staff-training programme that combines this preventive approach with the theoretical nursing framework of the City model that includes three staff factors: positive
appreciation of patients, emotional regulation and effective structure. We evaluated
this combination of the Bergen and City models on the violence prevention and
management climate in psychiatric inpatient wards. A 13-item questionnaire was
developed and distributed to patients and staff in 41 wards before the staff was trained
and subsequently to 19 of these wards after training. Data analyses included factor
analysis, Fishers exact test and MannWhitney U-test. The result showed that the staff
on trained wards had a more positive perception of four of the items and the patients
of one item. These items reflected causes of patient aggression, ward rules, the staffs
emotional regulation and early interventions. The findings suggest that a focus on three
levels of prevention within a theoretical nursing framework may promote a more
positive violence prevention and management climate on wards.

396

2012 Blackwell Publishing

Violence prevention and management staff training

Introduction
Patient aggression and violent behaviour are well-known
phenomena within psychiatric inpatient wards. Many
studies have described its negative influence on the experience of safety and security for both patients and staff: the
risk of physical and psychological injury and the use of
restraint, seclusion and forced medication (Olofsson &
Jacobsson 2001, Bowers et al. 2006b, Richter & Whittington 2006, Jarrett et al. 2008, Stubbs et al. 2009). In the
present study, we therefore wanted to explore how a violence prevention and management programme used in
Sweden may have influenced the ward climate in psychiatric inpatient units.

Background
Violence prevention and management is considered to be
an important as well as challenging part of inpatient psychiatric nursing and specific staff training is regarded as
essential (International Labor Office et al. 2002, Farrell &
Cubit 2005, Beech & Leather 2006). The various theories
concerning causes for inpatient aggression and violence are
often grouped into three explanatory models: the internal,
the external and the situational/interactional model
(Nijman et al. 1999, Duxbury & Whittington 2005). Traditionally, many violence prevention and management
training programmes for staff have relied mostly on the
internal patient explanatory model to violence (Paterson
et al. 2010). By assuming that the major cause of patient
violence is related to symptoms of mental illness and other
individual patient characteristics, a reactive and controlling
approach to aggression and violence has often been
applied. As a consequence, the training has been focused on
self-defence as well as various control and restraint techniques (Duxbury 2002, Farrell & Cubit 2005, Beech &
Leather 2006, Paterson et al. 2010). However, during the
last two decades, an increasing amount of research has
supported the view that violent patient behaviour is often a
result of a complex interplay of different internal, external
and situational/interactional factors (Richter & Whittington 2006). The current international recommendations
regarding violence prevention and management training of
staff in health-care settings therefore state that this complexity must be taken into account and that a proactive
rather than reactive approach should dominate the training
(Krug et al. 2002, Council of Europe 2004, International
Council of Nurses et al. 2005). Moreover, it should be
based on preventive principles of public health including
three dimensions of prevention: primary, secondary and
tertiary prevention (International Labor Office et al. 2002,
Krug et al. 2002). In psychiatric inpatient care, the aim of
2012 Blackwell Publishing

the level of primary prevention is to create an everyday

climate on the wards that minimizes the risk for violence
to develop. This includes, for example, good staffpatient
relationships, risk assessment, the use of care plans and an
adjusted physical ward milieu. Secondary prevention is
used when violence is perceived as imminent and often
comprises the use of de-escalation techniques. On the tertiary level a violent situation is already present and prevention may include taking safe physical control of a patient
as well as performing a post incident analysis (Delaney
& Johnson 2006, Paterson et al. 2009). The approach
requires action at the level of organization and management, the staff team, the individual staff member and the
individual patient (Paterson et al. 2005).
In order to establish the effects of various types of violence prevention and management staff training it is important that the programmes are systematically evaluated
(Johnson 2010). However, in two major review studies
of the effects of staff training, Richter et al. (2006) and
Johnson (2010) found that the varying quality and heterogeneity of the studies included in the reviews and the
numerous ways of defining and registering incidents made
evaluation of the effects difficult and that there was no clear
proof of a reduction of incidents as a result of staff training
(Richter et al. 2006). The most common outcome measurements were aggression incident rates and rates of coercive
measures. Several studies also included staff confidence in
dealing with aggression as well as changes in attitudes and
knowledge. Only one study included evaluation ratings
made by patients. This indicates that although the reduction of incident rates is an important outcome variable,
there is also a need for further evaluation focusing on
preventive variables that address the central parts of the
recommended proactive public health approach. Furthermore, qualitative variables such as ward climate and the
perspectives of both patients and staff may add further
depth and knowledge to a more comprehensive evaluation
process (Steinert 2002, Abderhalden 2008).
The aim of this study was to explore the influence of a
violence prevention and management staff-training programme, the Bergen model, used in Sweden, on the violence prevention and management climate in psychiatric
inpatient wards. For the purpose of this study, we coined
the term violence prevention and management climate
based on the previously described public health approach
to violence prevention and the theoretical nursing-based
framework of the City model (Bowers 2002). We defined
the term as within the dimensions of primary, secondary
and tertiary violence prevention, referring to the subjective perception of the staff and patients regarding staff
members positive appreciation of patients, their selfregulation of emotional responses and the efficacy of the
397

A. Bjrkdahl et al.

structure surrounding rules and routines, including the

general perception of safety and security on the ward.

Methods
We conducted a prospective non-randomized intervention
study with beforeafter intervention comparisons using an
independent measures design. The local research ethics
committee approved of the study. The study was conducted
in Stockholm, Sweden. In Sweden, employees working in
places where aggression and violence may be expected have
a legislated right to appropriate training provided by their
employer (Swedish Work Environment Authority 1993).
Within Swedish psychiatry, the arrangements have usually
been a matter for the local psychiatric clinics. Training
seems to have been provided by various sources such as
private training companies, self-defence or martial arts
sports clubs or by individual dedicated members of staff.
No common format for this type of staff training appears
to exist on the national level and the extent, content and
quality of such training programmes in Sweden has rarely
been systematically evaluated.

Intervention
The Bergen model is a non-commercial violence prevention
and management training programme for psychiatric inpatient staff. It originates from the Norwegian TERMA
training model that has been developed at the Haukeland
University Hospital, Department of Forensic Psychiatry in
Bergen. In Sweden, the TERMA model was first introduced at the psychiatric department of the Karolinska University Hospital, Huddinge in Stockholm. There, it was
subsequently adjusted to fit into Swedish general psychiatry
and renamed the Bergen model. In addition, the Bergen
model was adjusted to clarify a theoretical nursing framework, inspired by the public health approach (International
Labor Office et al. 2002) and strongly influenced by the
City model (Bowers 2002). The City model is a theoretical nursing-based framework that describes three staff
factors that are considered vital to reducing conflicts and
containment in psychiatric wards. These are: (i) positive
appreciation of patients, which refers to a psychiatric philosophy that promotes a psychological understanding of
difficult patient behaviour and a moral commitment to
values such as humanism and non-judgementalism; (ii) selfregulation of emotional responses, which includes awareness and control of feelings, especially fear and anger;
and (iii) effective structure of rules and routines, which
addresses teamwork skills, organizational support, clarity
of ward rules, early recognition of the interventions needed
and an organized manner in handling challenging situa398

tions. The City model has been used to guide several

intervention studies on psychiatric wards to study the
effects on aggression and violence (Bowers et al. 2006a,
2008, Bowers 2009).
The Bergen model puts forward primary prevention
factors based on good staffpatient relationships. The participants are encouraged to reflect on their own apparent
or unspoken approach to patients and patient aggression,
as well as the culture and organization of wards. The
training also includes aggression theory, ethics in care,
ward rules and routines, risk factors and risk assessment,
laws and legislations and the impact of the physical
environment. The secondary and tertiary sections of the
training address limit-setting styles and negotiation, selfdefence, physical restraint techniques (so-called pain compliance techniques are not used) and safety issues, the use
of mechanical restraint, seclusion and forced medication,
post-incident sessions with the patient and with the staff
and critical reviewing of violent incidents. If possible, participants are encouraged to allow conflict situations to
take time, to try to understand the background of the
situation and find a solution that is acceptable for everyone involved. Co-operation among all staff members and
between staff and patient is considered vital to the model.
The three staff factors of the City model work as guiding
principals on the primary, secondary and tertiary levels of
prevention of the training. The programme comprises a
4-day course for staff of all professions on psychiatric
wards, equally distributed between theoretically oriented
and practical sessions. Trainers are recruited and handpicked from clinically active staff within the clinic, and
trained in a special training trainers course (approximately 70 h) by Bergen model representatives. Following
the 4-day course, refresher classes are arranged and
offered regularly within the local clinics to all staff
members at least once every 6 months. The refresher
classes are based on the participants current experiences
with patients and colleagues and refer to both theory and
practice. The Bergen model has not been previously
subject to any systematic evaluation and the intervention
of this study could be described as a combination of the
Bergen and City models.
In 2006, the Stockholm County Council in Sweden
decided to start using the Bergen model in the violence
prevention and management staff training of the inpatient
psychiatric units within the organization. A senior manager
(the first author A.B.) with overall responsibility for the
introduction as well as the evaluation of the programme
was appointed by the central organization. The risk of bias
in the evaluation process was recognized and addressed by
involving co-researchers and by using theoretically derived
frameworks for the development of an evaluation question 2012 Blackwell Publishing

Violence prevention and management staff training

naire. The sample in this study comprised of patients and

staff on all of the 41 wards on the eight hospitals that
would undergo staff training according to the Bergen
model. The 41 wards were emergency and admission wards
(n = 2), general wards including wards for psychotic and
affective disorders (n = 30), psychiatric intensive care units
(n = 2), drug and alcohol dependence wards (n = 2) and
forensic wards (n = 5). Most wards consisted of 1218 beds
with 3035 nursing staff members along with a team of
multidisciplinary professions. The two emergency and
admission wards had each more than 50 employees. Prior
to the introduction of the Bergen model, the wards within
the organization were with few exceptions not involved in
any structured or regular staff training in violence prevention and management. Most new employees would,
however, in the beginning of their employment, participate
in a few days of self-defence training provided by a local
sports club.

Outcome measure
In order to evaluate the intervention, we sought a questionnaire that could be used for both patients and staff and that
adhered to the following premises: (i) each item would
relate to one or more of the three City model staff factors;
(ii) each item would be congruent to the content of the
Bergen model training programme and to the public health
approach; (iii) items should be observable by both staff and
patients; (iv) the number of items should be restricted,
making the questionnaire short and easy to use; and (v) the
items should be relevant to any type of psychiatric inpatient
ward. No such questionnaire was found in the literature.
We therefore formulated a number of questionnaire statements that were judged as specifically addressing all of
the stated premises and subsequently reduced them to a
13-item questionnaire. Of the 13 items, three were formulated as negative statements (item 4, 8 and 12) (DeVellis
2003). We called the questionnaire E13 (E being the first
letter in the Swedish word for questionnaire). For the
purpose of this paper, two professional translators conducted a translationcounter-translation process of the E13
from Swedish to English. The E13 was designed to collect
dichotomous data that would reflect the participants basic
agreement or disagreement to each of the questionnaire
statements. However, because participants may find it difficult to choose from only two response options, four levels
of agreement to the statements were included, from (1) not
at all, (2) unspecified, (3) unspecified, to (4) totally (Rossberg & Friis 2003). A fifth option, do not know, was also
available. Descriptive data included in the questionnaire
were for staff: sex, age category and occupation, and for
patients: sex and age category.
2012 Blackwell Publishing

Data collection
The data collection commenced in 2007. The E13 was
sent out to all participating wards (n = 41) 3 months
before the first wards were scheduled to start the training.
A research assistant was appointed on each participating
clinic to give information about the study and to distribute and collect questionnaires. The E13 was distributed to
all employed staff and to all patients that the staff assessed
as meeting the inclusion criteria. The criteria included the
ability to read and speak Swedish and the ability to understand the meaning of informed consent. Furthermore,
with respect to the mental and physical health of the
patient, the psychiatrist in charge was able to disapprove
of a patients participation. If possible, the E13 questionnaire was offered to the patients near discharge. An
enclosed letter described the purpose of the study and the
voluntary and anonymous nature of participation. No
coding or any other possibilities of identifying individual
patient or staff participants were made. Together with the
questionnaire, each participant received an unmarked
sealable envelope. A sealed box for collecting the questionnaires was placed on each ward. The data collection
continued for 1 month on each ward. Three to 6 months
after a ward had been trained, the same E13 questionnaire
was sent out again following the same procedures. In
December 2008, the data collection terminated. By then,
19 wards on six hospitals had finished their training and
completed the second round of the questionnaire (one
emergency and admission ward, 13 general wards, two
psychiatric intensive care units and three forensic wards).
Patient and staff turnover and the anonymity of the participants before and after the intervention meant that
the data were collected from independent samples. The
number of distributed questionnaires was not specifically
counted and response and exclusion rates were therefore
not known.

Data analysis
In order to analyse the interrelationship among the questionnaire items a factor analysis was performed, using
an exploratory principal component analysis including
varimax rotation and allowing for factors with an eigenvalue of >1.0 to emerge. In this analysis a three-factor
solution appeared. However, the three factors appeared
weak with a substantial cross-loading of >0.25 between
all factors on several items (Raubenheimer 2004). Furthermore, the second and third factor showed unsatisfactory internal consistency, Cronbachs a < 0.65 (Table 1).
Therefore we assumed that the 13 items may be viewed as
399

A. Bjrkdahl et al.

Table 1
Summary of exploratory principal component analysis for the E13 questionnaire
Rotated factor loadings
Item

7. Being on the ward feels safe and secure

5. The staff manage to calm aggressive patients down
6. The rules for patients on the ward are good
11. The staff approach patients already at the first signs of aggression
3. The staff co-operate when approaching aggressive patients
9. The staff are calm when approaching aggressive patients
1. The staff are often out on the ward with patients
10. The staff try to understand why a patient is acting aggressively
2. The relationship between staff and patients is good
13. Both female and male staff are involved in approaching aggressive patients
12. The staff are harsh with aggressive patients
8. Only certain members of staff are capable of approaching aggressive patients
4. Patients are often scared of other patients
Eigenvalues
% of variance
Cronbachs a

0.717
0.692
0.680
0.614
0.579
0.527
0.091
0.370
0.282
0.282
-0.069
0.224
0.404
4.558
35.2
0.729

0.092
0.232
0.064
0.408
0.427
0.478
0.736
0.560
0.525
0.407
0.294
0.184
-0.441
1.193
9.17
0.624

0.136
-0.007
0.170
0.148
0.093
0.182
0.047
0.292
0.197
0.264
0.721
0.649
0.557
1.027
7.90
0.400

The table shows the three-factor solution that was rejected in favour of a one-dimensional solution (Cronbachs a = 0.828).

measuring one dimension with no further meaningful

underlying components. This assumption was further
strengthened as the one-factor solution showed a satisfactory internal consistency, Cronbachs a = 0.83. As the
next step, the differences between the trained and the
untrained wards responses to each separate questionnaire
statement were calculated, using Fishers exact test.
Because data were collected on an independent, categorical level from different samples before and after the intervention, a dichotomization was made, which meant that
the nuances of the four levels of the response options
would not be considered in the analysis (DeVellis 2003).
This was made by sorting agreement options one and two
as a disagreement (no) and options three and four as an
agreement (yes). All questionnaires that included any of
the four agreement options for the particular item were
considered valid, excluding the response option do not
know. The data were calculated separately for patients
and staff. In order to further measure the impact of the
intervention, the effect size was calculated using odds
ratio (Field 2009). Finally, the difference between trained
and untrained wards was calculated for the questionnaire
as a whole. A sum score model was used based on the
dichotomized data. The model gave value 1 to statement
options three and four on all items except for the three
negative items (item 4, 8 and 12) where the value 1
was given to the statement options one or two. All other
options were given the value 0. Thus, a sum score range
for each questionnaire of 013 was obtained. The differences were analysed using MannWhitney U-test. All
questionnaires that included any of the four agreement
options on all 13 items were considered valid. P-values
of 0.05 were considered significant. All analyses were
400

performed using the spss software (version 16.0, IBM,

Armonk, NY, USA).

Results
Staff
A total of 854 staff questionnaires were collected from 41
wards before the training started and 260 staff questionnaires were subsequently collected from the 19 wards that
had been trained. Descriptive data for staff and patients are
presented in Table 2. In the analysis of the differences in the
total questionnaire sum scores, the perception was significantly more positive among staff on the trained wards as
compared with the wards that had yet not been trained,
MannWhitney P = 0.045. The results of the separate item
analysis showed that staff working on wards that had been
trained according to the Bergen model differed significantly
in their perception of violence prevention and management
climate regarding four of the 13 statements compared with
staff working on wards that had not yet been trained
(Table 3). The differences all corresponded to a more positive perception on the trained wards. The areas that were
perceived significantly more positive concerned ward rules
(statement 6), the emotional regulation of staff members in
challenging situations (statement 9), the staffs interest in
possible causes for patient aggression (statement 10) and
the staffs readiness to intervene at an early stage of patient
aggression (statement 11). In addition, just above the level
of significance was statement 2 concerning good relationships between patients and staff (P = 0.06) and statement
3 that related to the staffs ability to co-operate when
approaching aggressive patients (P = 0.058).
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Violence prevention and management staff training

Table 2
Descriptive data of staff and patients
Staff

Wards (n)
Total responses (n)
Responses/ward (n) (mean, range)
Female/male (%)
Age (%)
25
2640
>40
Occupation (%)
Nursing assistant
Registered nurse
Physician
Paramedic
Other

Patients

Before training

After training

Before training

After training

41
854
21 (256)
60/40

19
260
14 (419)
58/42

41
297
8 (118)
45/55

19
156
8 (120)
49/51

4
31
65

2
30
68

63
28
4
2
3

67
28
2
1
2

14
34
52

12
26
62

Table 3
E13 scale content: staff ratings before and after training, Fishers exact test P-value

Item
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.

The staff are often out on the ward with patients

The relationship between staff and patients is good
The staff co-operate when approaching aggressive patients
Patients are often scared of other patients
The staff manage to calm aggressive patients down
The rules for patients on the ward are good
Being on the ward feels safe and secure
Only certain members of staff are capable of approaching
aggressive patients
The staff are calm when approaching aggressive patients
The staff try to understand why a patient is acting aggressively
The staff approach patients already at the first signs of
aggression
The staff are harsh with aggressive patients
Both female and male staff are involved in approaching
aggressive patients

Before training % (n)

After training % (n)

Agree

Disagree

Agree

Disagree

Effect size
(odds ratio)

88.4
94.6
91.3
42.8
91.8
76.9
87.4
65.5

11.6
5.4
8.7
57.2
8.2
21.9
12.6
34.5

89.6
97.6
95.0
39.0
94.6
87.3
91.0
68.9

10.4
2.4
5.0
61.0
5.4
12.7
9.0
31.1

0.729
0.060
0.058
0.332
0.169
0.001*
0.144
0.348

1.12
2.31
1.85
0.86
1.56
1.97
1.45
1.17

(750)
(800)
(772)
(350)
(779)
(655)
(746)
(538)

(98)
(46)
(74)
(468)
(70)
(187)
(108)
(284)

(215)
(241)
(231)
(93)
(226)
(214)
(221)
(162)

(25)
(6)
(12)
(145)
(13)
(31)
(22)
(73)

88.6 (749)
83.8 (707)
80.3 (653)

11.4 (96)
16.2 (137)
19.7 (160)

94.5 (227)
89.4 (211)
89.5 (214)

5.5 (13)
10.6 (25)
10.5 (25)

0.007*
0.031*
0.001*

2.24
1.64
2.10

24.7 (201)
85.3 (719)

75.3 (612)
14.7 (124)

20.6 (49)
87.8 (208)

79.4 (189)
12.2 (29)

0.195
0.399

0.79
1.24

*P < 0.05.

Patients

Discussion

In the analysis of the differences in the total scores of

the patient questionnaire, no significant improvement was
found on the trained wards as compared with the untrained
wards, MannWhitney P = 0.471. The separate item analysis showed that patients staying on trained wards (n = 156)
differed significantly in their perception of violence prevention and management climate on one of the 13 statements
compared with patients staying on wards that had yet not
received training (n = 297) (Table 4). On the trained wards,
patients rated more positive perceptions of the staffs interest in finding possible causes for patient aggression (statement 10). There was also an almost significant difference
(P = 0.09) concerning a more positive perception of the
emotional regulation of the staff in challenging situations
(statement 9). No statement was rated significantly more
negative on the trained wards.

The City model (Bowers 2002) is an important and influential theoretical nursing framework of the Bergen model.
Thus, the Bergen model may serve as one example of how
the results of Bowers and colleagues intensive and longterm psychiatric nursing research on violence prevention
and management is used and implemented in clinical practice in Sweden. By using the City model as the foundation
of the construction of the E13, we believe that this questionnaire may be useful to evaluate the City model within
clinical practice in general and not only in the context of
the Bergen model.
The one statement that was more positively perceived by
the patients on trained wards as well as by the staff was
statement 10: The staff try to understand why a patient is
acting aggressively. Interestingly, this item reflects some
fundamental aspects of nursing, such as relating to and

2012 Blackwell Publishing

401

A. Bjrkdahl et al.

Table 4
E13 scale content: patient ratings before and after training, Fishers exact test P-value

Item
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.

The staff are often out on the ward with patients

The relationship between staff and patients is good
The staff co-operate when approaching aggressive patients
Patients are often scared of other patients
The staff manage to calm aggressive patients down
The rules for patients on the ward are good
Being on the ward feels safe and secure
Only certain members of staff are capable of approaching
aggressive patients
The staff are calm when approaching aggressive patients
The staff try to understand why a patient is acting aggressively
The staff approach patients already at the first signs of
aggression
The staff are harsh with aggressive patients
Both female and male staff are involved in approaching
aggressive patients

Before training % (n)

After training % (n)

Agree

Disagree

Agree

Disagree

Effect size
(odds ratio)

83.8
83.6
86.8
31.8
79.4
75.3
84.0
61.5

16.2
16.4
13.2
68.2
20.6
24.7
16.0
38.5

87.2
86.4
88.6
35.2
81.3
72.0
85.6
64.2

12.8
13.6
11.4
64.8
18.7
28.0
14.1
35.8

0.400
0.487
0.731
0.556
0.686
0.484
0.681
0.706

1.32
1.24
1.19
1.17
1.13
0.84
1.16
1.12

(249)
(245)
(177)
(78)
(185)
(217)
(247)
(112)

(48)
(48)
(27)
(167)
(48)
(71)
(47)
(70)

(130)
(127)
(109)
(43)
(109)
(103)
(134)
(68)

(19)
(20)
(14)
(79)
(25)
(40)
(22)
(38)

78.8 (175)
70.5 (146)
71.5 (138)

21.2 (47)
29.5 (61)
28.5 (55)

86.2 (119)
82.6 (95)
76.1 (89)

13.8 (19)
17.4 (20)
23.9 (28)

0.093
0.022*
0.428

1.68
1.98
1.27

38.6 (76)
86.4 (178)

61.4 (121)
13.6 (28)

35.3 (41)
88.0 (110)

64.7 (75)
12.0 (15)

0.629
0.738

0.87
1.15

*P < 0.05.

communicating with the patient as an individual (Peplau

1997, Delaney & Johnson 2006). Furthermore, this result
may demonstrate an increased openness and interest
among staff in more complex ways of viewing possible
causes of patient aggression (Duxbury 2002, Duxbury &
Whittington 2005). Because the statement 10 pictures an
already aggressive patient, it represents the secondary and
tertiary levels of prevention. By trying to understand the
patients reasons for behaving aggressively, the staff not
only has a better chance of finding a way to solve the
problem, but may also build a more trustful relationship
with the patient.
It is promising to find that the four more positively
perceived statements put together (statements 6, 9, 10 and
11) includes all three staff factors in the City model: staffs
positive appreciation of patients, emotional regulation and
effective structure (Bowers 2002). Moreover, the four statements also cover the three levels of the public health
approach to violence prevention (International Labor
Office et al. 2002). This suggests that the intention of the
Bergen model training programme to be based on the two
theoretical frameworks is realized in the staff training in a
way that makes it possible for the participants to put it into
nursing practice. Furthermore, it indicates that the E13
scale appears to have the capability to detect differences
within all the different aspects of the two theoretical
frameworks.
A proactive approach to patient aggression and violence
requires nurses to take an active and health-promoting role
towards the patients and in working together with the
multidisciplinary team. This is opposed to a more passive
or reactive role that involves waiting for signs of aggression
to appear and for other members of the ward team to make
the decisions regarding what actions is to be undertaken. In
402

an interview study, Bjrkdahl et al. (2010) suggested that

the caring approaches of nursing staff in acute psychiatry
appeared to vary between the different approaches of the
bulldozer and the ballet dancer, reflecting a range of
controlling and caring interventions. The authors found a
risk of the control-oriented bulldozer approach to become
uncaring and harmful to the nursepatient relationship. At
the same time, the nurses in the study described how the
bulldozer approach often involved high emotional strain
and a continuous inner dialogue on present ethical dilemmas. Similarly, when studying nurses limit-setting interventions on an acute psychiatric ward, Vatne & Fagermoen
(2007) found two simultaneous and conflicting perspectives: to correct and to acknowledge. The two perspectives reflected both a one-sided asymmetric nursepatient
relationship that the nurses felt often conflicted with their
ideals, which were geared towards understanding, valuing
and confirming the patient. The result of our present study
indicates that the combination of the public health perspective on violence prevention and the theoretical framework
of the City model in staff training may be a step forward
in the development of violence prevention and management interventions that are perceived by patients as not
only controlling but also caring. It is also possible that the
moral stress that nurses often experience in challenging
situations (Lutzen et al. 2010) would vane when substantial caring and preventive aspects become regularly and
consciously utilized components of the nurses approach
even on the levels of secondary and tertiary prevention.
Similar to the studies by Bowers and colleagues (Bowers
et al. 2006a, 2008, Brennan et al. 2006, Flood et al. 2006)
our study includes the theoretical framework of the City
model (Bowers 2002). When testing the theorys influence
on rates of conflict and containment on 136 acute psychi 2012 Blackwell Publishing

Violence prevention and management staff training

atric wards, it was found that the most important of the

three staff factors of the model, was related to effective
structure (Bowers 2009). Interestingly in our study, the one
item that was rated significantly higher by both patients
and staff on trained wards was related to the staff factor of
positive appreciation of patients (statement 10: The staff
try to understand why a patient is acting aggressively).
This may indicate that the staff factor of effective structure
could be of high relevance to the incident rates of patient
aggression and violence while the staff factor of positive
appreciation of patients may be more directed at evaluation
variables of a qualitative character such as the ward
climate. In another study, Hahn et al. (2006) used the
Management of Aggression and Violence Attitude Scale
(Duxbury 2003) to evaluate the effects of an aggression
management course on the attitudes of staff. No significant
difference was found after the training and the authors
suggested that beside attitudes, it may be important to also
evaluate the effect of training on affective components of
staff or practical handling skills (Hahn et al. 2006). This
shows that the E13 scale may prove useful because it
includes both affective and practically oriented statements
and also appears to be capable of detecting changes in
those components following staff training.

Methodological considerations
The methodological strength of this study includes the
participation of patients. The importance of including the
opinions of patients in the evaluation of effects of violence
prevention and management staff training has been emphasized in previous research (National Institute for Clinical
Excellence 2006). Nonetheless, literature reviews show that
this is still uncommon (Richter et al. 2006, Johnson 2010).
However, the result of this study should be interpreted with
caution and there are several methodological issues to be
addressed. The lack of control groups is a limitation of the
study design, which gives rise to uncertainty regarding to
what extent the observed changes were due to the staff
training or other confounding variables (Johnson 2010). It
should also be noted that the E13 scale was developed
without having the item pool reviewed by experts or prior
testing of the items on a development sample. Because the
psychometric testing was made directly on the research
sample, the robustness of the E13 scale should be further
established by a repeated factor analysis the next time the
scale is used. The interpretation of a factor analysis ultimately comes down to a subjective evaluation of what
solution appears to be the most meaningful in the light of
theory (DeVellis 2003). Our interpretation was in favour of
the E13 being a one-dimensional scale. In further testing,
this interpretation may be supported or challenged.
2012 Blackwell Publishing

Four of the items were significantly improved in the staff

ratings on trained wards compared with one item in the
patients ratings. This could indicate that the Bergen model
influences violence prevention and management climate
more positively for the staff than for the patients. At the
same time, it is likely that many of the staff members worked
on the same wards during the whole research period while
there was a constant flow of admittances and discharges of
patients. The improved staff ratings could, therefore, to a
higher degree than for the patients, reflect a comparison
between the wards violence prevention and management
climate before and after training. To implement sustainable
change in working culture takes time and it is possible that
the duration of the study was too short and that a third data
collection could have added further information on the
influence of the intervention. One strength of this study is
that the samples were relatively large. In future research, it
would however be valuable to explore the capacity of the
E13 to detect differences in smaller samples. In order to gain
statistical power, it is possible that dependent data should be
used, including all four response options.

Conclusion
The findings support to some extent that the Bergen training model has a positive influence on the violence prevention and management climate on the wards from the
perspectives of both patients and staff. The findings also
show that the combination of the public health approach to
violence prevention and the City model may be a promising example of a new integrated theoretical framework
that could become a valuable contribution to the development of staff training. Considering the heavy reliance on
the use of incident rates as the outcome variable of staff
training, the inclusion of measurements such as the E13
scale could present a more nuanced picture of the effects of
training, especially because it includes ratings made by
patients. Furthermore, the use of more complex evaluation
variables is also congruent with the current view on multiple causes for inpatient violence. In addition, it may
provide valuable feedback to staff and management in the
efforts to establish a ward climate characterized by an
atmosphere of safety and security.

Acknowledgments
This study was supported by funding from AFA Insurance
(a non-profit organization owned by Swedens labour
market parties). We want to thank the patients and nurses
who took the time to participate in this study. We are also
grateful to the European Violence in Psychiatry Research
Group and to Charlotte Pollak for valuable discussions and
assistance in the research process.
403

A. Bjrkdahl et al.

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