Antecedents to episodes involving aggression

Patient studies primarily identified antecedents within negative experiences of care related to restriction, loss of autonomy and poor interaction quality (e.g. ^{Reference Terkelsen and Larsen38,Reference Kontio, Anttila, Lantta, Kauppi, Joffe and Välimäki39,Reference Lamanna, Ninkovic, Vijayaratnam, Balderson, Spivak and Brook42} ), aligning with previous reviews. ^{Reference Fletcher, Crowe, Manuel and Foulds8,Reference Gudde, Olsø, Whittington and Vatne12} In contrast, staff studies more frequently located antecedents within denied requests, interpersonal conflicts and psychiatric symptoms (e.g. ^{Reference Bowers, Wright and Stewart34,Reference Renwick, Stewart, Richardson, Lavelle, James and Hardy55,Reference Pelto-Piri, Warg and Kjellin61} ).

Previous studies comparing patient and staff perspectives on antecedents to aggression suggest that this contrast may reflect that patients and staff draw on different explanatory models for understanding aggression. ^{Reference Duxbury and Whittington7,Reference Fletcher, Crowe, Manuel and Foulds8,Reference Ilkiw-Lavalle and Grenyer64,Reference Omérov, Edman and Wistedt65} Findings show that patients tend to perceive poor communication and environmental conditions related to restrictions as antecedents to aggression, whereas staff often viewed the patient’s mental illness as the main reason for aggression. ^{Reference Duxbury and Whittington7} A recent review also expands on these contrasts, emphasising staff perceptions of staffing and lack of resources as contributory to the development of aggression. ^{Reference Fletcher, Crowe, Manuel and Foulds8} These differences in understanding aggression may influence which antecedents are perceived as important, and accordingly emphasised in patient studies and staff studies.

This contrast may also partly be explained by in-patient ward cultures, characterised by competing priorities of care, control and safety. ^{Reference Duxbury and Whittington7,Reference Fletcher, Crowe, Manuel and Foulds8} Risk aversion is central to nursing care in mental health settings, ^{Reference Slemon, Jenkins and Bungay66} and staff often need to weigh patients’ needs against organisational needs. ^{Reference Manuel and Crowe67} Consequently, denied requests to maintain safety in staff studies may reflect situations perceived as restrictive in patient studies. Thus, when organisational needs are prioritised, these competing responsibilities may reinforce care experienced as restrictive, becoming points of tension in interactions between patients and staff. ^{Reference Fletcher, Crowe, Manuel and Foulds8} As a result, the antecedents emphasised in patient studies primarily draw attention to negative experiences of care developing over time, whereas the antecedents emphasised in staff studies direct attention to situations in which these experiences become visible through interactions between patients and staff.

Prevention efforts may therefore benefit from preventing negative experiences of care from accumulating over time, contributing to episodes involving aggression. This may involve how institutional restrictions and denied requests are communicated and implemented, as well as being attentive to patients’ expressions of distress before situations escalate. A previous review on patients’ experiences found that patients may communicate warning signs before episodes involving aggression, but that these are often ignored or misinterpreted. ^{Reference Gudde, Olsø, Whittington and Vatne12} Patient-centred communication and trauma-informed care may be relevant in this regard, as both emphasise choice, collaboration and trust, and encourage staff to consider how their actions may be perceived by patients. ^{Reference Fletcher, Crowe, Manuel and Foulds8,Reference Sweeney, Filson, Kennedy, Collinson and Gillard68} However, staff also need appropriate training, sufficient time and organisational support to engage with patients and respond flexibly when safety concerns arise.

Antecedents to episodes involving coercive measures

The antecedents to episodes involving coercive measures were also differently emphasised in patient and staff studies. However, unlike episodes involving aggression, staff studies frequently reported patient aggression preceding the use of coercive measures. This contrast is highlighted in recent systematic reviews comparing patient and staff experiences of coercive measures. ^{Reference Butterworth, Wood and Rowe6,Reference Almutairi, Price, Alqahtani, Marsden and Lovell11} Butterworth et al ^{Reference Butterworth, Wood and Rowe6} found that patients emphasise communication, autonomy, relationships and human rights as important to these episodes, whereas staff emphasised safety and the necessity of coercive measures. A similar contrast has been interpreted as two different types of knowledge. ^{Reference Almutairi, Price, Alqahtani, Marsden and Lovell11} Patients may draw on situated knowledge through experiences of care, which includes awareness of antecedents and their emotional sequelae, which may differ from the clinically and procedurally oriented knowledge typically found in staff studies. ^{Reference Almutairi, Price, Alqahtani, Marsden and Lovell11} As a result, antecedents may be emphasised differently across patient and staff studies.

Patient studies mainly identified antecedents within patients’ negative experiences of care, including poor communication, institutional restriction, loss of autonomy and controlling staff attitudes (e.g. ^{Reference Vermeulen, Doedens, Boyette, Spek, Latour and de Haan41,Reference Ling, Cleverley and Perivolaris44,Reference Ezeobele, Malecha, Mock, Mackey-Godine and Hughes52} ). This finding aligns with a previous review on patient experiences of coercion, noting that aggression was expressed as protest behaviour in response to loss of autonomy. ^{Reference Tingleff, Bradley, Gildberg, Munksgaard and Hounsgaard10} In a more recent systematic review comparing patient and staff experiences on the use of coercive measures, ^{Reference Butterworth, Wood and Rowe6} patient experiences highlighted that escalating behaviour was attributed to poor communication from staff. This suggests that patients experience episodes involving coercive measures as processes shaped by interactions, ^{Reference Tingleff, Bradley, Gildberg, Munksgaard and Hounsgaard10} and indicates that patient studies identify antecedents extending beyond the immediate events preceding coercive measures (e.g. ^{Reference Terkelsen and Larsen38,Reference Tölli, Kontio, Partanen and Häggman-Laitila51} ). Accordingly, attention should be drawn to how these episodes develop over time.

Conversely, staff studies primarily identified antecedents perceived as relevant to decisions about the use of coercive measures, including patient aggression, alongside denied requests, interpersonal conflicts and a wide range of patient characteristics (e.g. ^{Reference Iennaco, Whittemore and Dixon30,Reference Bowers, Wright and Stewart34,Reference Kang, Bushell, Lee, Berry, Hollander and Rauchberger35,Reference Di Lorenzo, Miani, Formicola and Ferri53} ). These findings align with previous studies showing that staff primarily view coercive measures as undesirable, yet necessary, responses to situations perceived as dangerous. ^{Reference Doedens, Vermeulen, Boyette, Latour and de Haan1,Reference Butterworth, Wood and Rowe6,Reference Almutairi, Price, Alqahtani, Marsden and Lovell11} Accordingly, the emphasised antecedents in staff studies may reflect the clinically and procedurally oriented knowledge available to staff when assessing the need for coercive measures. ^{Reference Almutairi, Price, Alqahtani, Marsden and Lovell11} Consequently, staff studies seem to draw attention to the more immediate circumstances in which coercive measures are considered necessary, which may partly explain why antecedents related to restriction or autonomy that develop over time may be less visible in staff studies. It should also be noted that, although rare, some antecedents reported for episodes involving coercive measures concerned patients’ perceived needs, such as the need for rest or a low-stimulus environment. ^{Reference Larsen and Terkelsen58,Reference Vruwink, VanDerNagel, Noorthoorn, Nijman and Mulder59} This suggests that staff studies do not consistently conceptualise coercive measures as responses to perceived risk, but also present them as therapeutic interventions.

The findings suggest that prevention efforts should focus on how episodes involving coercive measures develop over time and on the immediate circumstances in which coercive measures are considered necessary. Increased attention to patient needs and viewpoints during interactions, and providing patients sufficient time and the option to use personal coping strategies, may help prevent situations from escalating to the point where coercive measures are considered. ^{Reference Butterworth, Wood and Rowe6,Reference Tingleff, Bradley, Gildberg, Munksgaard and Hounsgaard10} Additionally, if and when coercive measures are considered, staff need the capacity to respond with safer and less restrictive alternatives. Previous studies suggest that this may require de-escalation skills, knowledge of individual patients, adequate support and resources, and access to options that staff consider feasible. ^{Reference Doedens, Vermeulen, Boyette, Latour and de Haan1,Reference Butterworth, Wood and Rowe6,Reference Almutairi, Price, Alqahtani, Marsden and Lovell11}

Fostering therapeutic relationships and collaboration may help integrate patients’ situated knowledge with staff’s clinical and procedural knowledge. This could allow patients’ experiences of restrictions, needs, warning signs and preferred responses to inform how staff understand and respond to escalating situations. In turn, it may also narrow the gap between how patients experience situations as escalating and the circumstances in which staff consider coercive measures as necessary.

Shared and specific antecedents across episodes involving aggression and episodes involving coercive measures

Within patient and staff studies, many antecedents were reported in relation to episodes involving aggression and episodes involving coercive measures, suggesting that the literature often describes these episodes as intertwined. The close relationship between aggression and coercive measures ^{Reference Wullschleger, Chieze, Courvoisier, Hurst, Sentissi and Kaiser69} also indicates potential for prevention by addressing shared antecedents before situations develop into aggression, or reach a point at which coercive measures are considered. The diversity and overlap of antecedents point to the need for comprehensive and multidimensional prevention efforts. Given that both episodes involving aggression and episodes involving coercive measures include patients and staff, prevention should draw on both perspectives while recognising the interplay between interactions, individual characteristics, structural conditions of care, and the policies and legal frameworks that guide them. ^{Reference Cutcliffe and Riahi22,Reference Cutcliffe and Riahi23,Reference Gooding, McSherry and Roper70}

These implications align with existing frameworks aimed at preventing the use of coercive measures, such as the Six Core Strategies, ^{Reference Huckshorn71} ReSTRAIN YOURSELF ^{Reference Duxbury, Baker, Downe, Jones, Greenwood and Thygesen20} and the Safewards model. ^{Reference Bowers19} Safewards may be of particular interest, as it provides an explicit link between aggression as a form of conflict and coercive measures as forms of containment within a model of how conditions on in-patient wards give rise to escalating situations. ^{Reference Bowers19} Accordingly, it provides a way of relating patients’ negative experiences of care involving loss of autonomy, restrictions and poor communication to the more immediate and observable circumstances emphasised in staff studies. Its interventions involve patient and staff and address their interactions, therapeutic relationships, collaboration and the ward environment. ^{Reference Bowers19} Notably, evaluation studies suggest that patients and staff may experience these interventions in complementary ways that align with the contrasting antecedents emphasised in this review. Patients described increased respect, safety, hope and a sense of community with staff, ^{Reference Fletcher, Buchanan-Hagen, Brophy, Kinner and Hamilton72} whereas staff described preventing conflicts differently, with a renewed sense of their impact on patients, while feeling safer and more

How the evidence base may influence which antecedents become visible

The review identified methodological characteristics of the evidence base that likely influenced which antecedents became visible in the included studies. Therefore, these characteristics should be considered when interpreting the findings of this review and when designing future studies. First, studies rarely held antecedents as the main focus, suggesting that the reported antecedents that emerged in studies may have addressed different research questions, not been explored systematically or not been explored in full depth.

Moreover, the reported antecedents in studies were seldom temporally specified. Some studies referred to broader experiences extending over time (e.g. ^{Reference Terkelsen and Larsen38,Reference Ezeobele, Malecha, Mock, Mackey-Godine and Hughes52} ), whereas others referred to immediate situations in close proximity to episodes (e.g. ^{Reference Sato, Noda, Sugiyama, Yoshihama, Miyake and Ito29,Reference Kang, Bushell, Lee, Berry, Hollander and Rauchberger35} ). Because studies define the beginning of episodes differently, this likely influences which antecedents become visible. The methods used to capture antecedents also likely influenced their visibility. Studies using quantitative methods based on data from incident reports primarily captured observable events occurring in close temporal proximity to episodes (e.g. ^{Reference Iennaco, Whittemore and Dixon30,Reference Richardson, Brennan, James, Lavelle, Renwick and Stewart49} ), whereas studies using qualitative methods based on interviews more commonly captured broader experiences (e.g. ^{Reference Lamanna, Ninkovic, Vijayaratnam, Balderson, Spivak and Brook42,Reference Ling, Cleverley and Perivolaris44} ).

The evidence base is also influenced by the imbalance between staff and patient studies and the near absence of patient involvement. Consistent with a previous review, ^{Reference Papadopoulos, Ross, Stewart, Dack, James and Bowers4} the predominance of staff studies may lead to antecedents perceived through clinical and organisational lenses being more frequently represented than antecedents concerning negative patient experiences with care. Studies that rely exclusively on incident reports are illustrative. The included Staff Observation Aggression Scale – Revised (SOAS-R) studies ^{Reference Sato, Noda, Sugiyama, Yoshihama, Miyake and Ito29–Reference Danivas, Lepping, Punitharani, Gowrishree, Ashwini and Raveesh31} rely on staff perceptions of a predefined set of provocations connected to the more acute and observable stages of episodes involving aggression. The studies therefore offer limited insight into how these episodes develop. These studies also report how aggression was managed, making aggression particularly visible as an antecedent to coercive measures. Because episodes involving aggression ^{Reference Cutcliffe and Riahi22,Reference Cutcliffe and Riahi23} and episodes involving coercive measures ^{Reference Bowers19} are interactional, multidimensional phenomena, future studies should draw on both patient and staff perspectives to inform practice, preferably within the same studies, while meaningfully involving patients throughout the research process.

Limitations of the evidence base

Limited patient involvement in studies may influence how antecedents are reported and interpreted in the literature. The predominance of staff studies limits balanced comparisons of antecedents and influences how shared and phenomenon-specific antecedents can be interpreted. Many studies report antecedents as secondary or incidental findings, obscuring whether shared and phenomenon-specific antecedents reflect conceptual variation or differences in reporting depth. Inconsistent conceptualisations and unclear temporal boundaries blur distinctions between immediate antecedents and broader situational conditions.

Limitations of the review

This scoping review has some notable limitations. First, no patients were involved in designing or conducting the review, which may have affected how the findings were interpreted. Second, antecedents were operationally defined to ensure consistency in study selection and data extraction because an explicit definition was rarely provided in previous reviews or the included studies. This operationalisation may have influenced how we identified and categorised antecedents. Although antecedents were categorised based on the level at which they were described to arise, this required prioritising one level of detail, which may have reduced nuance.

Third, restricting the review to English-language studies from the past decade may have excluded relevant literature. Most studies were conducted in a limited number of high-income countries, which may restrict generalisability. In accordance with JBI guidance, ^{Reference Peters, Godfrey, McInerney, Munn, Tricco, Khalil, Aromataris, Lockwood, Porritt, Pilla and Jordan16} a critical appraisal of studies was not conducted. The findings therefore reflect reporting patterns rather than the strength of the underlying evidence.

Future recommendations

This scoping review shows that the reported antecedents to episodes involving aggression or coercive measures become visible depending on the perspectives represented in studies, as well as how studies conceptualise, temporally describe and examine them. Patient studies mainly emphasised broader negative experiences of care. In contrast, staff studies more frequently emphasised concrete situations related to risk management and decisions about the use of coercive measures. The predominance of shared antecedents across episodes involving aggression and coercive measures within patient and staff studies indicates that these episodes are often described as parts of the same escalating process. However, patient studies and staff studies appear to highlight different parts of this process.

Prevention efforts may benefit from addressing antecedents across this escalation process, from patients’ broader experiences of care to the immediate situations in which staff perceive intervention to be necessary. Attention should be directed toward early interventions that incorporate both patient and staff perspectives through communication and collaboration, as well as organisational strategies that provide staff with adequate training, and support and promote ward cultures that better balance the needs of patients with organisational needs.

This review identified methodological and conceptual challenges that future studies should address. As studies inconsistently defined, conceptualised and temporally described antecedents, future studies should define and operationalise them more clearly and specify their temporal boundaries. As reported antecedents depend on the perspectives represented, patient involvement should be prioritised, along with incorporating both patient and staff perspectives. Moreover, future studies should clarify whether antecedents specifically concern episodes involving aggression, episodes involving coercive measures or both. This may lead to a more comprehensive understanding of how these episodes are described to develop, and how they are related within the literature.