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: [email protected].
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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,
9
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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Insert Table 2 about here
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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.
14
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
16
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.