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Cognitive factors in NHS staff responses to violence and aggression

By Emma Rebecca Bishop


NHS staff frequently experience violence and aggression, and post-traumatic stress disorder (PTSD) is amongst the potential psychological consequences. Using a prospective\ud design, the present study sought to establish whether cognitive factors, specified in Ehlers and Clark's (2000) model, could predict symptom severity over and above other established risk factors. The aim was to develop and refine a predictive tool, which could be used to identify\ud individuals who may benefit from early, targeted interventions. Forty-eight healthcare workers completed questionnaires assessing a range of cognitive factors, immediately following an incident of violence or aggression. Of these participants, twenty provided data concerning PTSD symptoms at three-month follow-up, despite implementing strategies to maximise response rates. It was therefore not possible to address the original research question owing to the small sample size. However, several participants reported experiencing symptoms, and for\ud some these were moderate to severe.\ud \ud Several potential reasons for non-response were identified, including the possibility that healthcare workers appraise workplace incidents in such a way that subsequent effects are minimised. An experimental analogue study examined this hypothesis. Student nurses (N = 190) read a vignette as an analogue for a violent incident, in which the context was manipulated. Results indicated that neither organisational setting (work / non-work), nor cause of the perpetrator's behaviour (illness / non-illness) influenced the type of appraisals endorsed, or ratings of perceived distress. It therefore seems likely that other factors contributed to the low response rate observed in Study 1. However, in line with Ehlers and Clark's (2000) cognitive model, appraisals explained a significant amount variance in dysfunctional behaviours after controlling for perceived distress.\ud \ud Study 1 indicated that a proportion of staff were adversely affected by incidents of violence and aggression. Replication of this research is warranted in light of the current literature, and recommendations are made for modification

Publisher: School of Medicine (Leeds)
Year: 2006
OAI identifier:

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  1. 19,2006, from http: //www.
  2. (2002). A brief screening instrument for post-traumatic stress disorder.
  3. (1986). A cognitive approach to panic. doi
  4. (2000). A cognitive model of posttraumatic stress disorder. doi
  5. (2001). A cognitive neuroscience account of posttraumatic stress disorder and its treatment. doi
  6. (1998). A comparison of normal forgetting, psychopathology, and information-processing models of reported amnesia for recent sexual trauma. doi
  7. (1996). A dual representation theory of posttraumatic stress disorder. doi
  8. (2002). A longitudinal study of "intrusion-based reasoning" and posttraumatic stress disorder after exposure to a train disaster. Behaviour Research and Therapy, doi
  9. (1983). A method of comparing the areas under receiver operating characteristic curves derived from the same cases.
  10. (1991). A program to help staff cope with psychological sequelae of assaults by patients.
  11. (2001). A prospective investigation of the role of cognitive factors in persistent posttraumatic stress disorder (PTSD) after physical or sexual assault. Behaviour Research and Therapy, doi
  12. (1991). A prospective study of patient assaults on nurses in a provincial psychiatric hospital in Canada. Psychiatrica Scandinavia Acta, doi
  13. (1999). A qualitative investigation of the organization of traumatic memories. doi
  14. (2003). A Safer Place to Work: Protecting NHS hospital and ambulance staff from violence and aggression, Report by the Comptroller and Auditor General HC527 Session 2002-03. London: The Stationary Office.
  15. (2000). A two-year prospective evaluation of the relationship between acute stress disorder and posttraumatic stress disorder following mild traumatic brain injury. doi
  16. (1999). Acute stress disorder and posttraumatic stress disorder in victims of violent crime. doi
  17. (1998). Acute stress disorder as a predictor of posttraumatic stress symptoms. doi
  18. (1996). Acute stress disorder, subsequent posttraumatic stress disorder and depression after a series of typhoons. doi
  19. (1994). American Psychiatric Association. doi
  20. (1961). An inventory for measuring depression.
  21. (2004). An investigation into interventions for individuals at high risk of developing psychological difficulties following traumatic injury. Unpublished doctoral thesis,
  22. (2001). Applying regression and correlation: A guide for students and researchers.
  23. (1988). Assaults on staff by psychiatric in-patients: A critical review. doi
  24. (2000). Assaults on staff by psychiatric patients in community residences. Psychiatric Services,
  25. (2003). Association, Health Policy and Economic Research Unit.
  26. (1989). Behavioral/cognitive conceptualisation of post-traumatic stress disorder. Behavior Therapy, doi
  27. (2006). Bullies who threaten NHS Staff to be shown the red card as new figures reveal 1 in 22 NHS workers suffer violence.
  28. (1993). Causal attributions and post traumatic stress in adolescents. doi
  29. (1991). Causal attributions and psychiatric symptoms in survivors of the Herald of Free Enterprise disaster. doi
  30. (1994). Causal attributions and recovery from rape and other stressful life events. doi
  31. (1995). Change in rape narratives during exposure therapy for posttraumatic stress disorder. doi
  32. (1997). Cognitive factors in persistent versus recovered post-traumatic stress disorder after physical or sexual assault: A pilot study. doi
  33. (1999). Cognitive factors involved in the onset and maintenance of posttraumatic stress disorder (PTSD) after physical or sexual assault. doi
  34. (2005). Cognitive Mechanisms and Posttraumatic Stress Disorder: Clinical and Analogue Research. doi
  35. (2003). Cognitive predictors of posttraumatic stress disorder in children: Results of a prospective longitudinal study. doi
  36. (1993). Cognitive processing therapy for rape victims. doi
  37. (2002). Cognitive processing, memory and the development of PTSD symptoms: Two experimental analogue studies. doi
  38. (2005). Cognitive therapy for PTSD: development and evaluation. Behaviour Research and Therapy, doi
  39. (1998). Data-driven versus conceptual processing questionnaire.
  40. (2003). Dealing with violent and aggressive patients: At what cost to nurses?
  41. (2002). Delayed-onset posttraumatic stress disorder: a prospective evaluation. doi
  42. (2006). Delayed-onset PTSD: A prospective study of injury survivors. doi
  43. (2004). Developing new treatments: On the interplay between theories, experimental science and clinical innovation. doi
  44. (2002). Dissociation and post-traumatic stress disorder: Two prospective studies of road traffic accident survivors. doi
  45. (1995). Dissociation and the fragmentary nature of traumatic memories: Overview and exploratory study. doi
  46. (2003). Does early psychological intervention promote recovery from posttraumatic stress? doi
  47. (2000). Dysfunctional meaning of posttraumatic intrusions in chronic PTSD. doi
  48. (2003). Early predictors of posttraumatic stress disorder. doi
  49. (2003). Early psychological interventions for adult survivors of trauma: A review. doi
  50. (2005). Effectiveness of providing self-help information following acute traumatic injury: randomised controlled trial. doi
  51. (2001). Effects of gender and ethnicity on duty-related posttraumatic stress symptoms among urban police officers. doi
  52. (2005). Enhanced priming for trauma-related material in posttraumatic stress disorder. doi
  53. (2005). Evaluation of premorbid personality factors and pre-event posttraumatic stress symptoms in the development of posttraumatic stress symptoms associated with a bus explosion in Israel. doi
  54. (2003). Exposure to terrorism, stress-related mental health symptoms, and coping behaviors among a nationally representative sample in Israel. doi
  55. (2006). from http: //www.
  56. (1989). Hidden Injury. Nursing Times,
  57. (1991). How many subjects does it take to do a regression analysis? Multivariate Behavioural Research, doi
  58. (2001). Incidence and prediction of posttraumatic stress disorder symptoms in severely injured accident victims. doi
  59. (1992). Incidence of PTSD among staff victims of patient violence.
  60. (1998). Insights of nurses about assault in hospitalbased emergency departments. doi
  61. (1999). International Council of Nurses. doi
  62. (1997). Introduction: what are memories? In
  63. intrusion- based reasoning in Vietnam veterans with and without chronic posttraumatic stress disorder. Behaviour Research and Therapy, doi
  64. (2004). Intrusive re-experiencing in post-traumatic stress disorder: Phenomenology, theory, and therapy. doi
  65. (2005). Longitudinal course of posttraumatic stress disorder and posttraumatic stress disorder symptoms in a community sample of adolescents and young adults. doi
  66. (2003). Management of workplace violence victims.
  67. (2000). Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. doi
  68. (2005). Nonsomatic effects of patient aggression on nurses: A systematic review. doi
  69. (1997). Past and present: Recovered memories and false memories. In doi
  70. (1995). Patients' threats. Expanded definition of assault. doi
  71. (2003). Post-trauma symptoms in health workers following physical and verbal aggression. Work and stress, doi
  72. (2006). Post-traumatic stress disorder following patient assaults among staff members of mental health hospitals: A prospective longitudinal study.
  73. (1993). Post-traumatic stress disorder in rape victims. In doi
  74. (2005). Post-traumatic stress disorder: The management of PTSD in adults and children in primary and secondary care. doi
  75. (2003). Posttraumatic disorders following injury: An empirical and methodological review. Clinical Psychology Review, doi
  76. (2002). Posttraumatic stress disorder after pre-eclampsia: An exploratory study. doi
  77. (1992). Posttraumatic stress disorder among injured survivors of a terrorist attack: Predictive value of early intrusion and avoidance symptoms. doi
  78. (2003). Posttraumatic stress disorder following assault: The role of cognitive processing, trauma memory, and appraisals. doi
  79. (2000). Posttraumatic stress disorder following political imprisonment: The role of mental defeat, alienation, and perceived permanent change. doi
  80. (2003). Posttraumatic stress disorder in the emergency room: Exploration of a cognitive model. Behaviour Research and Therapy, doi
  81. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. doi
  82. (1997). Predicting PTSD in civilian trauma survivors: Prospective evaluation of self-report and clinician administered instruments. doi
  83. (1997). Prediction of remission of acute posttraumatic stress disorder in motor vehicle accident victims. doi
  84. (2003). Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis. doi
  85. (2005). Predictors of posttraumatic stress disorder following cancer. doi
  86. (1994). Predictors of posttraumatic stress symptoms among survivors of the Oakland/Berkeley,
  87. (1996). Predictors of PTSD and injured trauma survivors: A prospective study.
  88. (2001). Prevalence and predictors of acute stress disorder and PTSD following road traffic accidents: Thought control strategies and social support. Behaviour Therapy, doi
  89. (1998). Prevalence and predictors of early traumatic stress reactions in assaulted psychiatric nurses. doi
  90. (2003). Psychological and emotional problems in staff following assaults by patients. Psychiatric Bulletin, doi
  91. (2002). Psychological debriefing for preventing post traumatic stress disorder (PTSD) (Cochrane review). doi
  92. (2003). Psychological mechanisms in acute response to trauma. doi
  93. (1998). Psychological predictors of chronic posttraumatic stress disorder after motor vehicle accidents. doi
  94. (2003). Psychological theories of posttraumatic stress disorder. doi
  95. (2004). Psychometric properties of the Posttraumatic Cognitions Inventory (PTCI): A replication with motor vehicle accident survivors. doi
  96. (1994). Psychometric theory. doi
  97. (2006). Psychosocial therapy for posttraumatic stress disorder. doi
  98. (1979). Quasi-experimentation: design and analysis issues for field settings. doi
  99. (1998). Relationship of acute stress disorder and posttraumatic stress disorder following mild traumatic brain injury. doi
  100. (1998). Relationship of acute stress disorder and posttraumatic stress disorder following motor vehicle accidents. doi
  101. (1999). Relationship of acute stress disorder and posttraumatic stress disorder: A two-year prospective study. doi
  102. (2001). Research governance framework for health and social care. doi
  103. (1998). Risk factors for posttraumatic stress disorder in Australian Vietnam veterans. Australian and New Zealand doi
  104. (2006). Risk factors for psychological distress following injury. doi
  105. (1996). Social reactions, coping strategies, and self-blame attributions in adjustment to sexual assault. doi
  106. (2002). SPSS version 10.1. Chicago: Author Salter,
  107. (2001). Stability of emotions for traumatic memories in acute and chronic PTSD. Behaviour Research and Therapy, doi
  108. (1992). Staff strain and social support in a psychiatric hospital following assault by a patient. doi
  109. (1988). Statistical power analysis for the behavioral sciences doi
  110. (1989). Stress reactions in an industrial accident.
  111. (1976). Stress response syndromes. doi
  112. (1997). Stress response syndromes. PTSD, grief and adjustment disorders. doi
  113. (1990). Structured Clinical Interview for DSM-III-R-Patient doi
  114. (1991). Supportive and unsupportive responses of others to rape victims: Effects on concurrent victim adjustment.
  115. (2006). Tackling nuisance or disturbance behaviour on NHS healthcare premises: A Department of Health consultation paper.
  116. (1989). The assaulted nurses: Short-term and long-term responses. Archives of Psychiatric Nursing,
  117. (2000). The cost of violence/stress at work and the benefits of a violence/stress free working environment. Geneva: International Labour Office.
  118. (2002). The effect of an education program on violence in the emergency department. doi
  119. (2005). The fallacy of ex-consequentia reasoning and the persistence of PTSD. doi
  120. (1997). The Impact of Event Scale - Revised. In
  121. (1991). The intrusive past: The flexibility of memory and the engraving of trauma.
  122. (1986). The moderator-mediator distinction in social psychological research: Conceptual, strategic and statistical considerations. doi
  123. (2005). The national audit of violence. London: Royal College of Psychiatrists.
  124. (2002). The nature of intrusive memories after trauma: The warning signal hypothesis. Behaviour Research and Therapy, doi
  125. (1999). The Posttraumatic Cognitions Inventory (PTCI): Development and validation. doi
  126. (1995). The Posttraumatic Diagnostic Scale (PDS)
  127. (1996). The prediction, experience and consequences of workplace violence. In doi
  128. (1983). The predictive power of diagnostic tests and the effect of prevalence of illness. doi
  129. (1983). The reactions of nursing staff to physical assault by a patient. Hospital and Community Psychiatry,
  130. (1997). The validation of a self-report measure of posttraumatic stress disorder: The Posttraumatic Diagnostic Scale. Psychological Assessment, doi
  131. (2002). The validity of the Hospital Anxiety and Depression Scale: An updated literature review. doi
  132. (2000). Thought suppression. Annual Review of Psychology, doi
  133. (1991). Traumatic events and posttraumatic stress disorder in an urban population of young adults. doi
  134. (1996). Traumatic memory characteristics: A cross-validated mediational model of response to rape among employed women. doi
  135. (1998). Treating the trauma of rape. Cognitive-behaviour therapy for PTSD. doi
  136. (1991). Treatment of posttraumatic stress disorder in rape victims: A comparison between cognitive-behavioural procedures and counselling. doi
  137. (1997). Understanding posttraumatic stress. A psychosocial perspective on PTSD and treatment. doi
  138. (2005). Unwanted memories of assault: What intrusion characteristics are associated with PTSD? Behaviour Research and Therapy, doi
  139. (1996). Using multivariate statistics doi
  140. (1995). Verbal aggression to psychiatric staff: Traumatic stressor or part of the job? Perspectives in Psychiatric Care,
  141. (1983). Violence against doctors: 2. Effects of violence on doctors working in accident and emergency departments. doi
  142. (2006). Violence against psychiatric nurses: Sensitive research as science and intervention. doi
  143. (1999). Violence at work: Findings from the British Crime Survey. London: Home Office.
  144. (2004). Violence at work: Findings frý om the British Crime Survey. Retrieved May 20,2006, from http: //www.
  145. (1991). Violence in general practice: A survey of general practitioners' views. doi
  146. (1999). Violence in mental health care: The experiences of mental health nurses and psychiatrists. doi
  147. (1999). Violence in the emergency department: A survey of health care workers. doi
  148. (1996). Violence to staff in a general hospital setting. doi
  149. (1987). Violence to Staff in the Health Services.
  150. (2001). Violence towards healthcare staff and possible effects on the quality of patient care. doi
  151. (1995). Violence: A public health priority. Geneva: World Health Organisation. doi
  152. (2003). Workplace violence in the health sector: country case study South Africa. Geneva: Joint Programme on workplace violence in the health sector (ILO/ICN/WHO/PSI).
  153. (2003). Workplace violence: Scope, definition and global context. Geneva:

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