Meta-analysis The antecedents of violence and aggression within psychiatric in-patient settings Papadopoulos C, Ross J, Stewart D, Dack C, James K, Bowers L. The antecedents of violence and aggression within psychiatric in-patient settings. Objective: To systematically review the types and proportions of antecedents of violence and aggression within psychiatric in-patient settings. Method: Empirical articles and reports with primary data pertaining to violence and aggression within adult psychiatric in-patient settings were retrieved. For each study, prospective antecedent data were extracted. The extracted antecedent data were thematically analysed, and all higher-level themes were meta-analysed using rate data. Results: Seventy-one studies met the inclusion criteria, from which 59 distinct antecedent themes were identified and organised into nine higher-level themes. The higher-level antecedent theme Ôstaff–patient interactionÕ was the most frequent type of antecedent overall, precipitating an estimated 39% of all violent ⁄ aggressive incidents. An examination of the staff–patient interaction themes revealed that limiting patients freedoms, by either placing some sort of restriction or denying a patient request, was the most frequent precursor of incidents, accounting for an estimated 25% of all antecedents. The higher-level themes Ôpatient behavioural cuesÕ and Ôno clear causeÕ also produced other large estimates and were attributed to 38% and 33% of incidents overall. Conclusion: This review underscores the influence that staff have in making in-patient psychiatric wards safe and efficacious environments. C. Papadopoulos 1 , J. Ross 2 , D. Stewart 3 , C. Dack 2 , K. James 3 , L. Bowers 3 1 Institute for Health Research, University of Bedfordshire, Bedfordshire, UK, 2 Faculty of Population Health Sciences, University College London, London, UK, 3 Institute of Psychiatry, Kings College London, London, UK Key words: psychiatry; violence; aggression; meta- analysis; review of the literature Chris Papadopoulos, Institute for Health Research, University of Bedfordshire, Room 32, Putteridge Bury, Hitchin Road, Bedfordshire, LU2 8LE, UK. E-mail: chris.papadopoulos@beds.ac.uk Accepted for publication December 16, 2011 Summations • The majority of violent and aggressive incidents across in-patient psychiatric settings are triggered when staff interact with patients. • Staff more readily record patient behavioural cues as antecedents compared with mood ⁄ emotional cues. • When staff is unsure of what precipitated an incident, they should pursue other potential sources of antecedent information. Considerations • There were significantly high levels of heterogeneity across the articles entered into each meta-analysis. • Articles predominantly reported the staffÕs perspective of antecedents. Therefore, the true nature and level of antecedents is questionable. • Some of the subgroup analyses were not comprehensive because of low study numbers Acta Psychiatr Scand 2012: 125: 425–439 All rights reserved DOI: 10.1111/j.1600-0447.2012.01827.x Ó 2012 John Wiley & Sons A/S ACTA PSYCHIATRICA SCANDINAVICA 425