Violence in mental health care: the experiences of mental health nurses and psychiatrists

An International Review of Workplace Violence Against Healthcare Providers: Sudan as a Case Study

Workplace violence experienced by healthcare providers (HCPs) in Sudan has gone viral, driving many HCPs outside the country. Globally, HCPs have accepted workplace violence as a phenomenon integral to their clinical work, causing an underreporting of incidents. This study reviews the causes and explores solutions for the phenomenon. Search strategies were conducted using internet sources including PubMed, Embase, Google Scholar, and Cochrane. References to Sudan were limited to HCPs in public healthcare facilities. A descriptive analysis was conducted on the global status of workplace violence toward HCPs. Future interventions were examined and discussed considering Sudan's circumstances. Results showed the "pandemic" nature of the phenomenon. Workplace violence contributes to the deterioration of the quality and efficiency of the healthcare system with consequences for effective healthcare delivery. It is concluded that a multiapproach intervention needs to be integrated to circumvent the standing multifactorial situation. Statutory actions are needed towards the widespread violence and impunity. Workplace organizational procedures are needed to address the patient's needs that overwhelm scarce resources. Robust educational efforts are recommended by HCP training bodies, the media, and other stakeholders to improve the doctor/patient relationship.

Violence in Health Care: Trends and Disparities, Bureau of Labor Statistics Survey Data of Occupational Injuries and Illnesses, 2011-2017

Background: The health care sector is one of the most rapidly growing industry sectors in the United States. This study examined differences in the rates and trends of violent occupational injuries among health care workers in the United States. Methods: This study used data about violent occupational injuries among health care workers in the United States collected by the Bureau of Labor Statistics (BLS) Survey of Occupational Injuries and Illnesses (SOII). The BLS SOII collects data about injuries that result in at least one lost workday. Violent injuries are defined as intentional injury by another person. Data were obtained for years 2011 to 2017. We examined injury rates and trends according to industry and occupation, as well as age, sex, and race/ethnicity. Results: Intentional injuries increased among health care workers between 2011 and 2017. Rates, expressed as injuries per 10,000 workers, were particularly elevated in residential care facilities (44.07) and among health practitioner support technologists and technicians (22.54); nursing, psychiatric, and home health aides (28.13); and occupational therapy and physical therapist assistants and aides (39.72). Black health care support and practitioners workers had injury rates three times higher than White workers. Conclusions/Application to practice: Efforts should be made to address the increasing rates of intentional occupational injuries among health care workers. These efforts should focus on comprehensive programs enforcing policies for prevention and management (including reporting and training) and employee engagement in such efforts. High-rate industries and occupations should receive particular attention.

Sources of Social Support After Patient Assault as Related to Staff Well-Being

Patient assault is a serious issue for the well-being of staff in psychiatric hospitals. To guide workplace responses to patient assault, more information is needed about social support from different sources and whether those supports are associated with staff well-being. The present study examines social support after patient assault from work-based and nonwork-based sources, and whether inpatient psychiatric staff desires support from them and perceive the support received as being effective. Received support across sources was examined in relations to staff well-being (physical health, mental health, anger, sleep quality) and perceptions of safety. Survey data was collected from 348 clinical staff in a large public forensic mental hospital. Among the 242 staff who reported an assault in the last year, 71% wanted support and 72% found effective support from at least one source. Generally, effective support from supervisors, coworkers, and their combination was associated with better well-being. Support from nonwork sources was related to less concerns about safety, but not to other well-being measures. However, 28% of staff did not receive effective support from any source postassault. Gaps in support as reported in this study and as found by other investigators call for systematic programming by hospital organizations to enhance the well-being of clinical staff, which in turn has implications for patient care.

Exploring staff conceptions of prevention and management practices in encounters with staff-directed aggression in supported housing following education and training

Background

Staff-directed aggression is a concern for service providers in mental healthcare, frequently affecting both the quality of services and staff wellbeing. This also applies to supported housing services for people with mental health problems. Staff themselves consider training to be an important route to improve the prevention and management of staff-directed aggression. The aims of this study are to explore how staff in community mental health supported housing services conceptualize practice in prevention and management of aggression and how these conceptions develop following a local education and training endeavor in disempowerment-sensitive, de-escalating and knowledge-based risk assessment and management.

Method

Phenomenography, a qualitative research approach, was adopted to pursue the study aims. The data consisted of 26 semi-structured interviews with 13 participants from five different municipal housing facilities in Oslo, Norway. Participants were interviewed on two occasions, once prior to participation and once subsequent to the finalization of the education and training sessions.

Results

The analysis led to the development of six qualitatively different, yet logically interrelated, categories of description regarding practice in encounters with staff-directed aggression: (1) Observation, alertness and awareness, (2) Established understanding and knowledge of service users, (3) Team-based risk management and deliberation, (4) Adaption of own dispositions and behaviors, (5) Reflexivity, sensitivity and care and (6) Involvement and dialogue. These conceptions were found to vary in meaning and focus; they ranged from implementing safeguarding and protective measures, to drawing on what was portrayed in terms of staff’s expert knowledge, to increasingly allowing for, and committing to, tenant perspectives in designing practice. The results indicate a moderate, yet beneficial, effect of the course on conceptual change in the participants.

Conclusion

This study shows that practice in encounters with staff-directed aggression is conceptualized as complex and multifaceted by staff in mental health supported housing services and that the various conceptions have different implications for the way staff-directed aggression is mitigated individually and collectively. Our findings also suggest that it is beneficial to take conceptual variation regarding practice into consideration when devising education and training aimed at enhancing staff knowledge, skills and practices.

'It comes with the territory' - Staff experience with violation and humiliation in mental health care - A mixed method study

BACKGROUND

The aim of this study was to investigate staff's experiences with violation and humiliation during work in mental health care (MHC). A total of 1160 multi-professional MHC staff in Norway responded to an online questionnaire about their experiences with different kinds of violation and humiliation in the MHC setting. In addition, a sample of professionals (eight MHC nurses) were recruited for in-depth individual interviews.

METHOD

The study used an explorative mixed method with a convergent parallel design; this included a web-based questionnaire to MHC staff in combination with individual interviews. The sample is considered to be equivalent to staff groups in MHC in Norway.

RESULTS

Between 70 and 80% of the staff reported experiencing rejection, being treated with disrespect, condescending behaviour or verbal harassment. Male workers were significantly more often victims of serious physical violence, and women were significantly more often targets for sexual harassment. In interviews, participants said they considered being exposed to violence and humiliation to be part of the job when working in MHC, and that experience, as well as social support from colleagues, helped MHC practitioners to cope better with violent situations and feel less humiliated at work.

DISCUSSION

A high amount of MHC staff report experiences of being violated and humiliated during work. The participants' perceptions of the users and their behaviour seem to influence their experience of feeling violated and humiliated. Knowledge about the dynamics of aggression between staff and users in MHC may be used in safeguarding staff and users, prevent coercion and heighten the quality of care.

Aggression and Violence Toward Healthcare Workers in a Psychiatric Service in Italy: A Retrospective Questionnaire-Based Survey

Workplace violence and aggression are receiving increasing attention, especially when perpetrated in at-risk services such as psychiatric and emergency departments. Many healthcare providers have been victims of verbal aggressions (VAs) and physical aggressions (PAs), as well as injuries (INs), at the hands of patients. We conducted a 1-year retrospective questionnaire-based survey to assess workplace violence and aggression experienced by staff working at the Psychiatric Service of the Health District of Bolzano-Bozen (Italy). We performed parametric statistics. Logistic regression estimated the size of the association between PA occurrence and staff characteristics. Our psychiatric service's employees were frequent victims (91.5%) of 1 or more aggression/injury in the previous year. VAs and INs showed comparable frequencies among the three sites of our service, that is, the inpatient (INP), the outpatient (OUTP), and the rehabilitation (REHAB) units, differently from PAs, which were more common at INP (p < 0.001). The logistic regression model showed that female sex, working at INP, and a shorter psychiatry work experience predicted PAs occurrence. Most of the staff felt they could benefit from aggression management. Findings show that VAs, PAs, and INs are common among our psychiatric service's employees and point to the need to provide staff training on de-escalation.

Folie du système? Preventing Violence Against Nurses in In-patient Psychiatry

Violence against psychiatric nurses is a difficult reality of work on in-patient psychiatry units. Health care providers and managers, nursing unions, and workplace protection agencies are looking for solutions to improve safety and quality of care. We are suggesting that simultaneous to this solution-seeking, there is also a need to critically reflect on the nature of violence itself within in-patient psychiatric settings. In this article we consider the gendered dynamics of power and violence within the in-patient psychiatric setting. The nursing profession is over 90% female. Given that violence in society often has a 'gendered' nature, and in light of a report from the Ontario Council of Hospital Unions which likened violence against nurses to domestic violence, we have put forth a view of the acute in-patient psychiatric milieu that considers gender and power in its analysis of violence against nurses. Intended to encourage enquiry into our pre-suppositions as health care providers, we use Foucauldian and feminist theories to up-end our notions of "anti-violence technologies", and to consider the unique and risky position that psychiatric nurses occupy as carers, care providers, and "anti-violence officers". We conclude by posing ethical questions which may be of interest for professional development, care planning, team building, and clinical ethics and education.

Encountering staff-directed aggression within mental health and substance abuse services: exploring conceptions of practice following education

Background

Staff-directed aggression represents a considerable concern in mental health and substance abuse services, and presents a substantial challenge to the quality and continuity of service provision for people with mental health and substance abuse problems. The practitioners themselves frequently request increased competence as a way to mediate the negative effects of staff-directed violence and aggression. The aim of this study is to explore how practitioners in municipal mental health and substance abuse services conceptualize practice in prevention and management of staff-directed violence. Furthermore, we seek to explore how these conceptions change following participation in two complementary and specially developed courses advancing respectively, qualified risk assessment and situational awareness and disempowerment-sensitive and de-escalation principles for practice.

Method

The study was conducted by using a qualitative phenomenographic research approach. The data-material comprised two-step semi-structured interviews with ten participants from various parts of community mental health and substance abuse services in the Municipality of Oslo, Norway.

Results

The analysis resulted in the development of five qualitatively different, hierarchically ordered, yet logically interrelated conceptual categories of practice concerning prevention and management of staff-directed aggression in community mental health and substance abuse services. These are: (1) Observation, reporting and expectation of organizational intervention, (2) Application of personalized de-escalating skills and behaviour, (3) Delivery of team-based and standardized services, (4) Provision of perceptive and responsive services, and (5) Facilitation of sensitive, involving and reflexive care. The categories vary according to the participants' attentional focus on either the responsibility of the organization, staff members' personally developed skills and techniques, team-based solutions, knowledgeable information processing in making professional judgements and reflexive, interpersonal service provision, as well as according to what meaning participants assign to practice. The authors have identified varying degrees of conceptual change following education in half of the participants.

Conclusion

The results of this study both show that practitioners conceptualize practice in aggressive encounters quite differently. The study also indicate that it is important to consider participant awareness of the phenomenon of interest when devising educational activities for personnel in mental health and substance abuse services.

Involving Patients and Families in the Analysis of Suicides, Suicide Attempts, and Other Sentinel Events in Mental Healthcare: A Qualitative Study in The Netherlands

Involving patients and families in mental healthcare is becoming more commonplace, but little is known about how they are involved in the aftermath of serious adverse events related to quality of care (sentinel events, including suicides). This study explores the role patients and families have in formal processes after sentinel events in Dutch mental healthcare. We analyzed the existing policies of 15 healthcare organizations and spoke with 35 stakeholders including patients, families, their counselors, the national regulator, and professionals. Respondents argue that involving patients and families is valuable to help deal with the event emotionally, provide additional information, and prevent escalation. Results indicate that involving patients and families is only described in sentinel event policies to a limited extent. In practice, involvement consists mostly of providing aftercare and sharing information about the event by providers. Complexities such as privacy concerns and involuntary admissions are said to hinder involvement. Respondents also emphasize that involvement should not be obligatory and stress the need for patients and families to be involved throughout the process of treatment. There is no one-size-fits-all strategy for involving patients and families after sentinel events. The first step seems to be early involvement during treatment process itself.

Preventing and managing workplace violence against healthcare workers in Emergency Departments

Background and aim: Healthcare workers (HCWs) employed in Emergency Departments (EDs) frequently face with patients becoming violent because of long wait or diseases or under the influence of alcohol or drugs. Globally, workplace violence (WPV) in EDs is a major challenge to safety for HCWs, involving significant consequences to the victims, patients, and healthcare organizations. We reviewed the current literature with the aim to explore the topics focused on and to detect new evidences about approaching the issue of WPV toward HCWs in EDs. Methods: A search for articles regarding WPV toward HCWs employed in EDs and published from January 2007 through December 2017 was performed; using predetermined criteria for inclusion, selected articles were reviewed and qualitatively assessed for the aims of the review. Results: We found 60 papers which matched our inclusion criteria; the topics, discussed in order of frequency from highest to lowest, were: “Risk Assessment”, “Occurrence Rates”, “Risk Management”, and “Physical/non Physical Consequences”. Dementia, schizophrenia, anxiety, acute stress reaction, suicidal ideation, and alcohol and drug intoxication were found as predictors of physical violence perpetrated by patients against HCWs. Conclusion: A strategic way to the effective management of WPV should prioritize training courses focused on: constructing HCW-patient relationship, improving the workers’ communication skills, accurate reporting of each violent incident, and improving the labor context through management commitment and employee involvement in WPV prevention programs. A special effort is required in implementing workplace design effective in minimizing stressful conditions in waiting rooms which turned out to be the most frequent site of assaults.

Well-Being and Safety Among Inpatient Psychiatric Staff: The Impact of Conflict, Assault, and Stress Reactivity

Psychiatric staff are faced with multiple forms of hostility, aggression, and assault at work, collectively referred to as workplace violence, which typically is activated by patients but can also come from coworkers and supervisors. Whether workplace violence adversely affects staff well-being may be related not only to its presence, but also to an individual's stress reactivity. At a large public psychiatric hospital, an online survey was completed by 323 clinical care staff, of whom 69.5 % had experienced physical assault in the previous 12 months. Staff well-being (depression, anger, and physical health) and staff safety concerns were adversely affected by conflicts with other staff members and by individual reactivity to social conflict and to assault. To improve staff well-being, in addition to safety protocols, interventions should target staff relationships, personal health maintenance practices, and individual coping skills for dealing with adverse workplace experiences.

The mental health of nurses in the UK

The recruitment and retention crisis in UK nursing puts many reforms outlined in recent health policies at risk. Increasing bureaucratisation of health care, unattractive working conditions, poor pay and the emotionally exhausting nature of the work are associated with high rates of burnout and workplace violence. Some nurses prefer agency work, some leave because they cannot reconcile a caring role with working in the NHS. It seems that health care has become emotionally distant and the profession's longstanding attachment to caring through interpersonal relationships has been overridden by a high-technology, fast-track system of care management. To retain the principles and ethos of nursing at the centre of health developments, attention must be given to the micro-environments in which nurses work.

Workplace Violence Toward Mental Healthcare Workers Employed in Psychiatric Wards

Background

Workplace violence (WPV) against healthcare workers (HCWs) employed in psychiatric inpatient wards is a serious occupational issue that involves both staff and patients; the consequences of WPV may include increased service costs and lower standards of care. The purpose of this review was to evaluate which topics have been focused on in the literature and which are new in approaching the concern of patient violence against HCWs employed in psychiatric inpatient wards, in the past 20 years.

Methods

We searched for publications in PubMed and Web of Science using selected keywords. Each article was reviewed and categorized into one or more of the following four categories based on its subject matter: risk assessment, risk management, occurrence rates, and physical/nonphysical consequences.

Results

Our search resulted in a total of 64 publications that matched our inclusion criteria. The topics discussed, in order of frequency (from highest to lowest), were as follows: “risk assessment,” “risk management,” “occurrence rates,” and “physical/nonphysical consequences.” Schizophrenia, young age, alcohol use, drug misuse, a history of violence, and hostile-dominant interpersonal styles were found to be the predictors of patients’ violence.

Conclusion

Risk assessment of violence by patients appeared the way to effectively minimize the occurrence of WPV and, consequently, to better protect mental HCWs. We found paucity of data regarding psychologic sequelae of WPV. According to these findings, we suggest the need to better investigate the psychologic consequences of WPV, with the aim of checking the effective interventions to assist HCW victims of violence and to prevent psychologic illness.

Patients' bill of rights and effective factors of workplace violence against female nurses on duty at Ilam teaching hospitals

BACKGROUND

Workplace violence against female nurses is an increasing problem. In addition, recognition the rights of patients can reduce such violence against female nurses. Therefore, the aim of the current study was to investigate workplace violence against female nurses in respect with patients' bill of rights at two public hospitals of Ilam in 2012.

METHODS

In a descriptive cross-sectional research, workplace violence against female nurses was studied. Data were gathered employing a researcher made questionnaire filled out by 106 female nurses. The questionnaire was on workplace, physical and verbal violence of patients and their attendants, and also the patient's rights as respected by nursing staff. Permission of university ethics committee was obtained. Data analyses were done by T-test and ANOVA in SPSS software.

RESULTS

Totally, 90.6 % and 15.1 % of the participants were subjected to verbal and physical assaults by patients, respectively during last year of the study. Further, 92.5% and 11.3% of nurses experienced verbal and physical assaults by the patients' attendants, respectively. Most of the nursing staff believed that reporting aggressive attacks to the concerned officials would not be useful. A negative significant correlation was found between the aggressions of patients with age as well as marital status of nurses, (P= 0.04). Furthermore, a significant association was seen between physical violence of patients and the nurses' recognition of the patients' bill of rights (P= 0.03).

CONCLUSIONS

Due to high rate of violence against female nurses, some proper and effective actions such as employing a trained security force along with legal punitive charges against violators through responsible officials are highly suggested.

Physical injury and workplace assault in UK mental health trusts: An analysis of formal reports

Workplace violence is a significant problem for health service personnel, with National Health Service (NHS) workers subject to 68 683 physical assaults between 2013 and 2014. Almost 70% of assaults occur in the mental health sector, and although serious, non-fatal injury is rare, the individual and economic impact can be substantial. In the present study, we analysed mandatory incident reports from a national database to examine whether there were identifiable precursors to incidents leading to staff injury, and whether staff characteristics were associated with injury. In line with previous descriptions, we found injury occurred either as a direct result of patient assault or during physical interventions employed by staff to contain aggression. Importantly, we found little evidence from staff reports that patients' symptoms were driving aggression, and we found less evidence of patient perspectives among reports. We make several recommendations regarding the reporting of these events that could inform policy and interventions aimed at minimizing the likelihood of injury.

Feeling "overloaded" and "shortcomings": milieu therapists' experiences of vulnerability in caring for severely mentally ill patients

Background

Milieu therapists’ relationships with patients with severe mental illnesses are viewed as challenging. Elucidating vulnerability from their perspective in daily face-to-face encounters with patients might contribute to extending our knowledge about milieu therapists’ vulnerability and the dynamics of the interaction between patients in mental health services and expertise in building caring and therapeutic relationships. The aim of this project was to study educated milieu therapists’ experiences of their own vulnerability in their interactions with patients in mental health services.

Materials and methods

The data collection method was focus-group interviews. Thirteen part-time master’s in mental health students (eight nurses, three social workers, two social educators) participated. All participants had experience with community or specialized mental health services (2–8 years).

Results

The milieu therapists mainly related their experiences of vulnerability to negative feelings elicited by challenging work conditions, disclosed as two main themes: 1) “overloaded”, by the possibility of being physically and mentally hurt and the burdens of long-lasting close relationships; milieu therapists were extremely vulnerable because of their difficulty in protecting themselves; and 2) “shortcomings”, connected to feelings of despair associated with not acting in concordance with their professional standards and insecurity about their skills to handle challenging situations, which was a threat to their professional integrity. There seemed to be coherence between vulnerability and professional inauthenticity. A misunderstanding that professionalism refers to altruism seems to increase milieu therapist vulnerability.

Conclusion

Vulnerability in health care is of interest to multiple disciplines, and is of relevance for knowledge development in higher education. Extended knowledge and understanding about milieu therapists’ vulnerability might strengthen their personal and professional integrity in professional practice in mental health services. Health care managers’ focus on the supervision of individual professionals in practice and practical training is important. Further research on the coherence between vulnerability and professionalism is recommended.

Predictors of workplace violence among ambulance personnel: a longitudinal study

Aim

To examine predictors of repeated confrontations with workplace violence among ambulance personnel, the proportion of exposure to potentially traumatic events that are aggression‐related and to what extent personnel was able to prevent escalations. Although previous research assessed the prevalences among this group, little is known about predictors, to what extent PTE's are WPV‐related and their abilities to prevent escalations.

Design

A longitudinal study with a 6 months' time interval (N = 103).

Methods

At T1 demographics, workplace violence and potentially traumatic events in the past year, mental health, personality, handling of rules, coping and social organizational stressors were assessed. Confrontations with aggression were also examined at T2.

Results

Multivariate logistic regression analyses showed that only problems with superiors independently predicted repeated verbal aggression and that only the (absence of the) ability to compromise very easily predicted repeatedly being on guard and repeatedly confronted with any form of aggression. Due to very low prevalences, we could not examine predictors of repeated confrontations with physical aggression (N = 5) and serious threat (N = 7). A large majority reported that in most workplace violence cases they could prevent further escalations. About 2% reported a potentially traumatic event in the year before T1 that was WPV related and perceived as very stressful.

Registered nurses' experiences of patient violence on acute care psychiatric inpatient units: an interpretive descriptive study

BACKGROUND

Nurses working in acute care psychiatry settings experience high rates of patient violence which influences outcomes for nurses and the organization. This qualitative study explored psychiatric nurses' experiences of patient violence in acute care inpatient psychiatric settings.

METHODS

An interpretive descriptive design guided this study that included 17 semi-structured interviews with a purposeful sample of 12 Canadian registered nurses who self-reported experiencing patient violence within acute care inpatient psychiatry. Thematic analysis and constant comparison techniques were used for analysis. A problem, needs and practice analysis was also used to structure overall data interpretation.

RESULTS

Thirty three unique exposures to patient violence among the sample of nurses were analysed. Nurses reported experiencing physical, emotional and verbal violence. For many, patient violence was considered "part of the job." Nurses often struggled with role conflict between one's duty to care and one's duty to self when providing care following a critical incident involving violence. Issues of power, control and stigma also influenced nurse participant perceptions and their responses to patient violence. Nurses used a variety of strategies to maintain their personal safety and to prevent, and manage patient violence. Nurses endorsed the need for improved education, debriefing following an incident, and a supportive work environment to further prevent patient violence. Present findings have implications for reducing the barriers to reporting violent experiences and the creation of best practice guidelines to reduce patient violence in the workplace.

CONCLUSIONS

Understanding the perspectives and experiences of nurses in acute inpatient psychiatry leads to greater understanding of the phenomenon of patient violence and may inform the development of interventions to prevent and to respond to patient violence, as well as support nurses working within the acute care setting.

Registered nurses' experiences of patient violence on acute care psychiatric inpatient units: an interpretive descriptive study

Background

Nurses working in acute care psychiatry settings experience high rates of patient violence which influences outcomes for nurses and the organization. This qualitative study explored psychiatric nurses’ experiences of patient violence in acute care inpatient psychiatric settings.

Methods

An interpretive descriptive design guided this study that included 17 semi-structured interviews with a purposeful sample of 12 Canadian registered nurses who self-reported experiencing patient violence within acute care inpatient psychiatry. Thematic analysis and constant comparison techniques were used for analysis. A problem, needs and practice analysis was also used to structure overall data interpretation.

Results

Thirty three unique exposures to patient violence among the sample of nurses were analysed. Nurses reported experiencing physical, emotional and verbal violence. For many, patient violence was considered “part of the job.” Nurses often struggled with role conflict between one’s duty to care and one’s duty to self when providing care following a critical incident involving violence. Issues of power, control and stigma also influenced nurse participant perceptions and their responses to patient violence. Nurses used a variety of strategies to maintain their personal safety and to prevent, and manage patient violence. Nurses endorsed the need for improved education, debriefing following an incident, and a supportive work environment to further prevent patient violence. Present findings have implications for reducing the barriers to reporting violent experiences and the creation of best practice guidelines to reduce patient violence in the workplace.

Conclusions

Understanding the perspectives and experiences of nurses in acute inpatient psychiatry leads to greater understanding of the phenomenon of patient violence and may inform the development of interventions to prevent and to respond to patient violence, as well as support nurses working within the acute care setting.

Workplace violence against nurses in Chinese hospitals: a cross-sectional survey

OBJECTIVES

To determine the prevalence of workplace violence that Chinese nurses have encountered, identify risk factors and provide a basis for future targeted interventions.

SETTING

Heilongjiang, a province in northeast China.

METHODS

A cross-sectional survey.

PARTICIPANTS

A total of 588 nurses provided data. There were also in-depth interviews with 12 nurses, 7 hospital administrators and 6 health officials.

RESULTS

A total of 7.8% of the nurses reported physically violent experiences and 71.9% reported non-physically violent experiences in the preceding year. Perpetrators were patients or their relatives (93.5% and 82%, respectively), and 24% of nurses experienced non-physical violence that involved Yi Nao (gangs specifically targeting hospitals). Inexperienced nurses were more likely to report physical (13.2%) or non-physical (89.5%) violence compared with experienced nurses. Graduate-level nurses were more likely to perceive and report non-physical violence (84.6%). Nurses who worked rotating shifts were 3.668 times (95% CI 1.275 to 10.554) more likely to experience physical violence, and 1.771 times (95% CI 1.123 to 2.792) more likely to experience non-physical violence compared with nurses who worked fixed day shifts. Higher anxiety levels about workplace violence and work types were associated with violence. Interviewees perceived financial burdens, unsatisfactory treatment outcomes and miscommunications as influencing factors for workplace violence.

CONCLUSIONS

Preplacement education should focus on high-risk groups to reduce workplace violence. Increased awareness from the public and policymakers is necessary to develop effective control strategies at individual, hospital and national levels.

Risk assessment and absconding: perceptions, understandings and responses of mental health nurses

AIMS AND OBJECTIVES

This paper reports mental health nurses' perspectives of absconding. The aims of the study were to explore nurses' perceptions of risk assessment and management practices regarding absconding from acute inpatient psychiatric settings, and their affective responses when patients absconded.

BACKGROUND

Nurses are directly involved in managing the risk of patients leaving hospital while acutely unwell, as well as dealing with the implications of an absconding event. However, despite their key role, few studies have explored nurses' perceptions of absconding.

DESIGN

An interpretive inquiry was undertaken using a systematic thematic approach.

METHODS

Mental health nurses (n = 11) from three acute inpatient mental health units in Australia took part in semi-structured interviews, with a focus on the nurses' experiences of working with patients who had absconded. Data were analysed using systematic thematic coding procedures.

RESULTS

Nurses' assessment of a patient's risk of absconding involved the use of clinical judgement, focusing on markers of absconding including the patient's history and clinical presentation. The acuity of the perceived risk determined the type of risk management strategy implemented, which could include support, observation and/or the use of containment procedures. Nurses responded with a myriad of affective reactions when patients absconded depending on their assessment of the patient's risk.

CONCLUSIONS

Support and debriefing is required for mental health nurses following an absconding event. Additional research is vital to identify alternative absconding assessment and management strategies to ensure the best possible outcome for patients and nurses.

RELEVANCE TO CLINICAL PRACTICE

Mental health nurses play a central role in risk assessment and management for absconding, with fear of repercussions a significant consequence for them. This research highlights the importance of both clinical judgment and standardised instruments in assessing absconding risk. Further research is needed to identify alternative evidence-based absconding management strategies to support nursing practice.

Dealing with violent and aggressive patients: at what cost to nurses?

Objectives: To determine the attitudes and experiences of nursing staff in relation to violent and aggressive patients.

Method: A self-administered questionnaire booklet was distributed to 289 nursing staff working in ‘high-risk’ units within two NHS Trusts. In addition to assessing the frequency of violent incidents, the degree of burnout and post-traumatic symptoms experienced were assessed by the inclusion of two standardised measures in the survey, viz, the Maslach Burnout Inventory and the Impact of Event Scale-Revised respectively.

Results: One hundred and fifty six (54%) nurses responded to this survey. Over two-thirds of nurses (72%) had been physically assaulted during the previous two years. The longterm psychological impact of these incidents was not related to whether or not a physical injury was sustained. A positive correlation between burnout and exposure to verbal abuse, threatened assault and violence was demonstrated.

Conclusions: Nurses in these Trusts are exposed to an unacceptable level of violence or aggression from patients, potential implications of which include post-traumatic reactions and burnout. However, nurses are reluctant to report incidents of verbal abuse or threats formally, and they rely upon the support of their colleagues following ‘distressing’ incidents. To protect the wellbeing of their staff, hospital management needs to consider preventative measures, such as training and personal alarms, and improved reporting systems to ensure all incidents are accurately recorded.

Frequency and risk factors of workplace violence on psychiatric nurses and its impact on their quality of life in China

This study examined the frequency of violence on nurses in Chinese psychiatric hospitals and explored its risk factors and impact on nurses' quality of life (QOL). A survey was conducted with 387 frontline psychiatric nurses in China. Information about experience of workplace violence in the past 6 months, type of workplace violence, and demographic characteristics was collected by a questionnaire. Altogether 319 (82.4%) of 387 nurses reported having experienced at least one type of violent event in the past 6 months. The prevalence of sexual assault, physical and verbal harassment was 18.6%, 61.5% and 78.6%, respectively. Compared to those with no exposure to violence, nurses who were exposed to violence had lower QOL in both the physical and mental domains. Significant predictors of violence against nurses are male sex, receiving college level or higher education and working on rotating duty were independently associated with high risk of violence. Workplace violence against psychiatric nurses commonly occurs in China. Considering the deleterious effects of violence, comprehensive strategies from the perspective of nursing education and training, organizational policy, patient care and staff support are recommended to promote occupational safety in psychiatric settings in China.

Ready, aim fire! Mental health nurses under siege in acute inpatient facilities

It has been clearly acknowledged and well-documented that physical, emotional, and psychological violence is a central theme and an expected workplace hazard for registered nurses working in acute inpatient mental health care facilities. Limited research, however, has focused on how registered nurses have been able to cope within this environment and adequately protect themselves from harm. A critical feminist research project recently explored the lived experience of 13 Australian, female, registered nurses working in a busy metropolitan acute inpatient mental health care facility. "Fear" was exposed as the precursor to violence and aggression, both "fear as experienced by the nurse" and "fear as experienced by the patient." The participants reported experiencing a sense of fear when they could not accurately or confidently anticipate a patient response or reaction. They identified this relationship with fear as being "part of the job" and part of the unpredictable nature of caring for people experiencing complex distortions in thinking and behavior. The participants believed, however, that additional workplace pressures complicated the therapeutic environment, resulting in a distraction from patient care and observation. This distraction could lead to nurse-patient miscommunication and the potential for violence. This article discusses a major theme to emerge from this study, "Better the devil you know!" The theme highlights how mental health nurses cope with violence and why they choose to continue working in this complex care environment.

Psychiatric nursing as 'different' care: experience of Iranian mental health nurses in inpatient psychiatric wards

Patients with mental illness require unique and specific care. The purpose of this study was to explore the experiences of nurses, who provide such care for mentally ill people, within the context of Iranian culture. This hermeneutic phenomenological study was carried out in a university-affiliated hospital in an urban area of Iran. We interviewed 10 mental health nurses to capture in detail their experiences in psychiatric units, and the approach developed by Diekelmann et al. was employed to analyse the data. Four themes and five sub-themes were identified: 'being engaged with patients' (sub-themes: 'struggle for monitor/control', 'safety/security concerns', 'supporting physiological and emotional needs'), 'being competent', 'altruistic care' and 'facing difficulties and challenges' (sub-themes: 'socio-cultural' and 'organizational challenges'). The results provide valuable insights and greater understanding of the professional experiences of psychiatric nurses in Iran, and indicate the need for a stable and responsible organizational structure for those nurses who are expected to manage patient care in psychiatric wards.

Facing the challenges and building solutions in clinical psychiatric nursing in Iran: a qualitative study

Psychiatric nurses play an important role in the process of caring for mentally ill patients and are continually faced with the numerous challenges and complex issues related to this field. This study aimed to understand the perspectives of psychiatric nurses regarding the issues they face while providing care and examine the possible solutions for improvement of inpatient care in clinical settings. The study adopted a qualitative approach that utilized a content analysis of audio taped, semi-structured interviews that had been conducted with 24 nurses. Two main themes emerged from the data. The first, Challenges in Providing Care within Psychiatric Wards, had the following subthemes: Politics and Rules of Organization, Safety and Security Issues, Uncertainty about the Role, Lack of Trained Staff, and Sociocultural Issues. The second theme, Solutions for Improving Psychiatric Care, had the subthemes of Empowerment across four domains: Psychiatric Nurses, Mentally Ill Patients and their Families, The Psychiatric Mental Health System, and the Cultural Context. The results indicated that if nurses are expected to provide optimal nursing care within a psychiatric ward, then there is a need for a stable and responsible organizational structure, skilled psychiatric nurses, and community-based care along with an anti-stigma program.

Registered nurses' and behavior health associates' responses to violent inpatient interactions on behavioral health units

BACKGROUND

Violence carried out by patients against nursing staff unsettles and threatens coworkers as they care for individuals admitted to inpatient psychiatric units.

OBJECTIVE

This study explored nursing staff's individual and group responses to violent incidents performed by patients against caregivers.

DESIGN

This qualitative study used focus groups to collect data from professional nurses and behavioral health associations (N = 19) recruited from urban, inpatient psychiatric unit. Data were analyzed thematically.

RESULTS

Sharing information about violence, intervening therapeutically, intervening nontherapeutically, recognizing team influences, experiencing emotions following violence, and understanding the work environment comprised the major themes of the experience.

CONCLUSIONS

Findings may stimulate discussions and education sessions that address strategies helpful to nursing staff so that incidents are prevented and staff is supported following such disturbing events. Events of workplace violence, including those occurring on behavioral mental health in inpatient units, require accurate individual and aggregate reporting to develop interventions and evaluate effectiveness of violence reduction strategies.

Psychometric properties of the Turkish version of the perception of aggression scale

The aim of this study was to investigate the psychometric properties of the Turkish version of the Perception of Aggression Scale. Cross-sectional data were collected by the completion of questionnaires by 350 nursing students from two nursing schools in Istanbul, Turkey. The psychometric properties of the Turkish version of the scale were analysed by using factor analysis (principal component analysis), assessment of internal consistency and reliability, and Spearman's rank correlation coefficients. The two-factor structure was confirmed by principal component analysis: the first factor treated aggression as functional and the second as dysfunctional. The correlation between the means of the items and dimensions was moderate (r for factor 1: 0.47-0.73; r for factor 2: 0.29-0.70). The coefficient of internal consistency of the scale was 0.85 for factor 1 and 0.81 for factor 2. Thus, Turkish version of Perception of Aggression Scale is a valid and reliable tool. It is essential to understand perceptions of aggressive behaviour in order to establish effective management strategies to tackle untoward events in clinical settings.

The relationship between seclusion and restraint use and childhood abuse among psychiatric inpatients

Seclusion and restraint (S/R) is a controversial topic in the field of psychiatry, due in part to the high rates of childhood physical and sexual abuse found among psychiatric inpatients. The trauma-informed care perspective suggests that the use of S/R with previously abused inpatients may result in retraumatization due to mental associations between childhood trauma and the experience during S/R. Thus, though one would expect to see efforts on the part of inpatient psychiatric facilities to limit S/R of previously abused inpatients, research suggests that trauma victims may be more likely to experience S/R. The current study sought to clarify this possibility by examining whether presence or absence and chronicity of childhood sexual and physical abuse differed among three groups of adult inpatients (N = 622) residing at a mid-Western state psychiatric hospital. These groups are empirically derived on the basis of dramatic differences in the patterning of their exposure to S/R over the course of hospitalization. Results of Chi-square and Kruskal-Wallis tests suggest that the classes did not significantly differ in presence or absence and chronicity of childhood sexual or physical abuse when male and female inpatients were analyzed separately. However, among the class of inpatients who experienced the most instances of S/R, 70% of the members have histories of childhood abuse. Implications for inpatients, clinicians, and policy makers are discussed.

The Brøset Violence Checklist: clinical utility in a secure psychiatric intensive care setting

Violence towards health-care workers, especially in areas such as mental health/psychiatry, has become increasingly common, with nursing staff suggesting that a fear of violence from their patients may affect the quality of care they provide. Structured clinical tools have the potential to assist health-care providers in identifying patients who have the potential to become violent or aggressive. The Brøset Violence Checklist (BVC), a six-item instrument that uses the presence or absence of three patient characteristics and three patient behaviours to predict the potential for violence within a subsequent 24-h period, was trialled for 3 months on an 11-bed secure psychiatric intensive care unit. Despite the belief on the part of some nurses that decisions related to risk for violence and aggression rely heavily on intuition, there was widespread acceptance of the tool. During the trial, use of seclusion decreased suggesting that staff were able to intervene before seclusion was necessary. The tool has since been implemented as a routine part of patient care on two units in a 92-bed psychiatric centre. Five-year follow-up data and implications for practice are presented.

Barriers and motivating factors in reporting incidents of assault in mental health care

BACKGROUND

There is a high incidence of assault against nursing staff in mental health care. Efforts to reduce the incidence of assault are hindered by the complexity and nature of the problem and by the fact that incidents of assault are underreported.

OBJECTIVE

To identify factors influencing nurses to report staff assault by patients in an inpatient mental health care facility.

DESIGN

The study used a modified nominal group technique in which nurses worked together to identify themes in decisions about reporting incidents of assault. The participants were nurses at two sites of a mental health care organization.

RESULTS

Nurses used a complex decision-making process to decide whether an incident of assault was worth reporting. Safety culture, the design of the incident reporting system, and the effect on patients were important components of the decision-making process.

CONCLUSION

Strategies that consider all levels of the organization's system should be used to improve reporting of assault incidents.

Perceived aggression towards nurses: study in two Italian health institutions

AIMS

The goal of the present study was to quantify the perceived aggression towards nurses working in two Italian health care institutions and to verify the hypothesis of an association between the characteristics of aggressors and the type of aggression.

BACKGROUND

Violence and aggressiveness, particularly aimed at nurses, are a common, but inadequately investigated phenomenon in Italian health care institutions.

DESIGN

A cross-sectional study.

METHODS

The study was performed, studying a sample of 700 nurses (37% of the personnel in 94 units) in two health care institutions in northeast Italy using an anonymous multiple-choice questionnaire.

RESULTS

Forty-nine percent of the nurses responded that they had experienced aggression in the previous year, 82% of that was only verbal. This happened more often to female nurses working in the emergency department and in geriatric and psychiatric units. A statistically significant association (p < 0.001) was found between the perception of fatigue, stress and work dissatisfaction and the frequency of aggression. Aggressors were usually patients or their relatives (57%) and were mainly men (66%). Fifty-three percent of assaulted nurses did not ask for help after the event.

CONCLUSIONS

This study confirms the high incidence of perceived, mainly verbal aggression towards nurses.

RELEVANCE TO CLINICAL PRACTICE

Action to prevent aggressive episodes may include concentrating on job motivation, encouraging participatory leadership and promoting the best possible working conditions. The absence of any systematic event reporting and documentation makes the assaulted workers feel defenceless.

A narrative review of the effectiveness of aggression management training programs for psychiatric hospital staff

Workplace violence, including patient-perpetrated violence in healthcare settings, is increasingly being recognized as preventable. Staff training has been identified as a necessary component of any initiative aimed at preventing or reducing incidents of aggression and violence in the workplace. This narrative review of the literature evaluates the effectiveness of staff training programs designed to prevent and manage violence and aggression in psychiatric hospitals. An exhaustive review of the literature was performed on all articles published in English between January 1, 1990 and April 1, 2007 that evaluate an aggression management training program. Twenty-nine studies met the inclusion criteria for a full review and were summarized using a qualitative narrative approach. Aggression management training has been proven effective in some areas, such as reducing the use of restraints and other coercive control devices, but more methodologically rigorous research is needed to firmly establish whether it is effective in reducing aggression and staff injuries.

IMPLICATIONS

The findings of this study suggest that relying too heavily on aggression management staff training will have limited effect on addressing the range of issues related to patient-perpetrated violence in psychiatric hospitals. Mental healthcare organizations must look beyond staff training if they are to achieve meaningful reductions in aggressive incidents and staff injuries.

The 12-month prevalence of patient-initiated aggression against psychiatrists: a New Zealand national survey

OBJECTIVES

We surveyed the prevalence of various types of threats or assaults by patients against psychiatrists and determined the impact of the most distressing event.

METHOD

An anonymous questionnaire was mailed to all 308 vocationally registered psychiatrists practicing in New Zealand.

RESULTS

A response rate of 63.9% (n = 197) was obtained. In the preceding 12 months, as many as 46% (n = 89) of respondents had been verbally threatened and 39% (n = 76) had been physically intimidated by patients. In addition 16% (n = 32) had been assaulted without requiring medical attention, 14% (n = 27) had been harassed through formal complaint mechanisms, 10% (n = 20) had been sexually harassed, and 5% (n = 9) had been stalked. As indicated by responses on the Impact of Event Scale, only one-third of the psychiatrists had any symptoms related to the most distressing event and only two had symptoms that might be associated with clinically significant levels of distress.

CONCLUSIONS

The prevalence of these events suggest a need for the development and evaluation of preventive interventions.

Physical assault by patients against physiotherapists working in mental health settings

OBJECTIVES

There is a lack of empirical research about physical assault by patients against physiotherapists who work in mental health settings. This study aimed to ascertain the lifetime prevalence and 12-month incidence of assault by patients against physiotherapists in UK mental health settings. This research will inform the development of pre- and post-registration training programmes for physiotherapists.

DESIGN

Postal questionnaire survey.

PARTICIPANTS

Members of the Chartered Society of Physiotherapists' special interest group for physiotherapists working in the field of psychiatry.

MAIN OUTCOME MEASURES

Self-reported experience of physical assault by patients. Secondary outcome was self-reported training received to manage violent and aggressive patients.

RESULTS

Questionnaires were returned by 116/178 (65%) special interest group members. Fifty-one percent (59/116) reported that they had been assaulted at work during their career, and 24% (28/116) had been assaulted by a patient in the previous 12 months. Physiotherapists in mental health settings appear to be at greater risk of assault by patients than other non-nursing clinicians.

CONCLUSIONS

Physiotherapists who work in mental health are at similar risk of physical assault by patients as their nursing colleagues, who are required by the UK Nursing and Midwifery Council to receive education and training in the prevention and management of aggression and violence in their pre-registration training. The authors recommend that appropriate training should be included in pre-registration programmes for physiotherapists.

Workplace violence: a survey of paediatric residents

BACKGROUND

Paediatric residents are often exposed to verbal abuse and/or physical assaults from patients and patients' families during the course of their training. Residents may benefit from further training on how to prevent and respond to workplace violence.

AIMS

To determine the prevalence of workplace violence in paediatric residency training programmes.

METHODS

In 2007, a 25-item web-based questionnaire about experiences of verbal and/or physical abuse while on duty was distributed to 1211 paediatric residents at all training levels from 25 paediatric programmes.

RESULTS

A total of 541 questionnaires were returned giving a 45% response rate. In total, 33% of the respondents had been verbally abused or physically assaulted by patients and/or patients' families during their residency programme, although verbal abuse was much more common than physical assaults. In total, 71% of respondents reported having no teaching about workplace violence during their residency training. The majority (74%) indicated that they would like to receive more training in managing angry patients and families.

CONCLUSIONS

Paediatric residents are often exposed to verbal threats during the course of their work. They are also at risk of physical assaults by angry patients and/or families. Paediatric residents require more training on how to prevent and respond to workplace violence, and this important topic should be incorporated into the paediatric residency curriculum.

An evaluation of nurses' interpersonal styles and their experiences of violence

Nursing is a demanding and stressful occupation. Nursing staff is required and expected to develop an interpersonal style that conveys concern for mentally ill patients. This study is aimed at investigating whether staff attitudes and behaviours are related to assaults on nurses in psychiatric settings. One hundred, sixty-two nurses working in psychiatric hospitals participated in this descriptive and analytical study. The data were gathered with an Interview Form and The Interpersonal Style Inventory. The statistical analysis shows that nurses who are less social and less tolerant are more exposed to physical assaults from patients, however nurses who are more help-seeking are more exposed to verbal assaults and have a concern of being assaulted. The findings of this research suggest that nurses' interpersonal styles may contribute to aggressive behaviours of patients/relatives.

Multiple perspectives on assault: the 360-degree interview

Workplace violence is common in health care settings. The authors review various models of this violence that have developed over time. From a linear model, understanding progressed to an interactional and then to a contextual model of assault that examines interactions of the aggressor, victim, and the environment. To date, there has not been a satisfactory research methodology to explore the complexities of the contextual model. This article proposes the 360-degree evaluation as an appropriate methodology for examination of multiple perspectives on assault. The 360-degree model allows comparison of perspectives of the assailant, victim, victim's peers, and victim's supervisor. J Am Psychiatr Nurses Assoc, 2009; 14(6), 413-420.