Staff strain and social support in a psychiatric hospital following assault by a patient

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.

Violence in the workplace: some critical issues looking at the health sector

BACKGROUND

The literature on occupational violence and even more the literature on violence against nurses in health settings have evidenced inconsistencies regarding how workplace violence has been conceptualized.

PURPOSE

To review and discuss some inconsistencies regarding how workplace violence against nurses in health settings has been conceptualized paying special attention to the challenges posed to the health of nurses stemming from patients, visitors or co-workers.

METHOD

Review of data of the European Working Conditions Surveys, and National Surveys on Working Conditions in Spain.

DISCUSSION

It is necessary to overcome these conceptual inconsistencies on violence in order to carry out intervention programmes based on solid theoretical grounds.

CONCLUSIONS

Violence against nurses takes place within an organisational climate defined by role relationships. The organizational climate can either reduce the likelihood of violence or, on the contrary, instigate violent behaviors.

[Barriers to and facilitators for using a risk assessment tool to prevent violent behaviour in patients with mental health conditions: Perspectives of health care providers]

Regular assessment of risk of violence is shown to be effective in reducing violence in mental health services.

PURPOSE

To evaluate health care providers' use of a violence risk assessment tool on a mental health unit and the facilitators for and barriers to its use.

METHODS

A descriptive study using the Dillman approach and informed by the Knowledge to Action framework was conducted.

RESULTS

Twenty-six health care providers responded to the survey; 62% reported using the violence risk assessment tool available on their unit, but not on a daily basis. Common barriers were lack of knowledge of the tool, lack of resources and time, and negative attitudes toward patients. 42% of participants indicated the need for further training on violence risk assessment.

CONCLUSION

Despite high exposure to violence, health professionals were not conducting daily risk assessments. The barriers and facilitators identified provide direction for interventions that are necessary if the daily use of violence risk assessment tools is to be increased.

Implementing Non-violent Resistance, a Method to Cope with Aggression in Child and Adolescent Residential Care: Exploration of Staff Members Experiences

Staff members in residential care for youth are frequently confronted with aggressive behaviour, which has adverse effects on their stress levels and work satisfaction. This paper describes a qualitative evaluation to find out how staff members benefit from Non-violent Resistance (NVR), a method to create an aggression mitigating residential climate. Staff members were positive about NVR and reported feeling more relaxed. Most valued aspects of this method were the focus on being a team, delayed response and giving up the illusion of control. However, training and the intention to use NVR isn't enough, high quality implementation and maintenance are crucial.

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.

Experiencing violence in a psychiatric setting: Generalized hypervigilance and the influence of caring in the fear experienced

BACKGROUND

Exposure to violence in the mental health sector both affects employees and has implications for the quality of care provided.

OBJECTIVE

This phenomenological study aims to describe and understand the ways in which acts of aggression from a patient might affect workers in a psychiatric institute, their relationships with the patients and the services offered.

METHODS

Two semi-structured interviews were conducted with each of the 15 participants from various professions within a psychiatric hospital.

RESULTS

Our analysis reveals four themes: hypervigilance, caring, specific fear toward the aggressor and generalized fear of all patients. A state of hypervigilance is found among all participants. An emphasis on caring is present among the majority and unfolds as a continuum, ranging from being highly caring to showing little or no caring. A feeling of fear is expressed and is influenced by the participant's place on the caring continuum. Caring workers developed a specific fear of their aggressor, whereas those showing little or no caring developed a generalized fear of all patients. Following a violent event, caring participants maintained this outlook, whereas those demonstrating little to no caring were more inclined to disinvest from all patients.

CONCLUSIONS

Hypervigilance and fear caused by experiences of violence impact the quality of care provided. Considerable interest should thus be paid to caring, which can influence fear and its effects.

Linking Workplace Aggression to Employee Well-Being and Work: The Moderating Role of Family-Supportive Supervisor Behaviors (FSSB)

PURPOSE

The present study examined the moderating effects of family-supportive supervisor behaviors (FSSB) on the relationship between two types of workplace aggression (i.e., patient-initiated physical aggression and coworker-initiated psychological aggression) and employee well-being and work outcomes.

METHODOLOGY

Data were obtained from a field sample of 417 healthcare workers in two psychiatric hospitals. Hypotheses were tested using moderated multiple regression analyses.

FINDINGS

Psychiatric care providers' perceptions of FSSB moderated the relationship between patient-initiated physical aggression and physical symptoms, exhaustion and cynicism. In addition, FSSB moderated the relationship between coworker-initiated psychological aggression and physical symptoms and turnover intentions.

IMPLICATIONS

Based on our findings, family-supportive supervision is a plausible boundary condition for the relationship between workplace aggression and well-being and work outcomes. This study suggests that, in addition to directly addressing aggression prevention and reduction, family-supportive supervision is a trainable resource that healthcare organizations should facilitate to improve employee work and well-being in settings with high workplace aggression.

ORIGINALITY

This is the first study to examine the role of FSSB in influencing the relationship between two forms of workplace aggression: patient-initiated physical and coworker- initiated psychological aggression and employee outcomes.

Violence toward Health Care Workers

The aim of this study was to establish data for career prevalence and 1 year incidence of workplace violence for major categories of health care workers. Three consecutive work environment questionnaire studies at a large Swedish hospital provided the basis for the study. Prevalence and incidence rates of violence were age and gender adjusted to the Swedish working population. Prevalence of violence in the study population was compared to data from a national sample of Swedish registered nurses. Incidence of violence in each professional group was compared to that of the largest group of hospital employees, registered nurses. Standardized prevalence ratios for violence were significantly higher for all nursing personnel and physicians, and were highest for practical nurses (1.56). Standardized incidence rates ranged from 18/100 person years for physicians to 31/100 person years for practical nurses. The relative risk for violence at work over a 1 year period was significantly higher only for practical nurses (1.59) as compared to registered nurses. Nursing personnel and physicians were at considerable risk for workplace violence in the course of their careers. One year incidence rates were highest for practical nurses.

Influence of staff's emotional reactions on the escalation of patient aggression in mental health care

Patient aggression is universally recognized as an important challenge in mental health care (MHC). Based upon a pragmatic exploration of the professional literature, we seek here to determine how negative emotional reactions of staff-including those conveyed in terms of fear, anger, and insult-may serve to exacerbate this serious impediment to safe and effective MHC. This is done using biological and evolutionary paradigms. Studies of patient aggression have tended to focus more on patient characteristics and behavior than on those of their caregivers. The authors suggest that patient aggression may be viewed as a response to "normal" interaction processes. The results of this investigation imply that the emotional reactions of staff may escalate the aggressive interaction by increasing the patient's perception of threat, and also, increase the probability of new incidents by creating a patient-staff relationship characterized by unsafety and mistrust. Mindfulness-based interventions are suggested as useful strategies to expand the staff's emotional awareness and increase emotional control.

Self-esteem in mental health nurses: Its relationship to stress, coping and burnout

This paper examines the relationship between self-esteem and stress, coping and burnout in mental health nurses (n=568). Self-esteem is said to be one of the most important moderating variables in determining the effects of stress on individuals. The modified Rosenberg Self-Esteem Scale was administered to nurses in both hospital and community, along with a range of other standardised measures. While there were no significant differences in self- esteem between the two groups of mental health nurses, smokers and drinkers in the sample were found to have significantly lower levels of self- esteem. Equally, nurses who felt happy with their life, were physically fit and who had job security, had higher self-esteem scores. Self-esteem correlated highest with measures of stress. Multiple regression analyses showed that happiness was one of the best predictors of self-esteem. Evidence is also presented on the discriminative validity of the concept of self-esteem. Enhancing nurses' levels of self-esteem may help reduce staff stress levels. Future nursing stress research needs to examine the role of other moderating variables.

Resilience and Professional Quality of Life in Staff Working with People with Intellectual Disabilities and Offending Behavior in Community Based and Institutional Settings

Staff in forensic services for people with intellectual disabilities (ID) are expected to deal with a wide range of emotional challenges when providing care. The potential impact of this demanding work has not been systematically explored previously. This article explores the professional quality of life (QoL) and the resilience (hardiness) of the staff in this setting. The Professional QoL questionnaire and the Disposional Resilience Scale were completed by staff (n=85, 80% response rate) in the Norwegian forensic service for ID offenders. Responses from staff working in institutional settings were compared to those from staff in local community services. Staff in the local community services had higher resilience scores compared to the staff in the institutional setting, (t=2.19; P<0.05). However in the other QoL and resilience domains there were no differences between the staff in the two settings. The greater sense of resilient control among community staff may be a function of both the number of service users they work with and the institutional demands they face. Even though these participants worked with relatively high risk clients, they did not report significantly impaired quality of life compared to other occupations.

Support Our Staff--a unique program to help deal with patient assault

PURPOSE

The program "Support Our Staff" was developed to provide assaulted staff with the most current information and coping strategies.

CONCLUSIONS

Participants reported being helped by the program and felt better prepared to cope with future assaults. However, victims felt blamed for the disruption caused by the assault and resented the lack of support from management.

PRACTICE IMPLICATIONS

Management needs to take responsibility for their role in violence within the institution, allowing staff to escape the isolation and guilt. Reporting must be encouraged and staff asked to contribute to the development of efficient programs, thus leading to a sense of empowerment.

Occurrence of post traumatic stress symptoms and their relationship to professional quality of life (ProQoL) in nursing staff at a forensic psychiatric security unit: a cross-sectional study

Background

Violence is frequent towards nurses in forensic mental health hospitals. Implications of this high risk environment have not been systematically explored. This paper explores occurrence of symptoms on post traumatic stress and their relationship to professional quality of life.

Methods

Self report questionnaires assessing symptoms of post traumatic stress and professional quality of life were distributed among psychiatric nurses in a high security forensic psychiatric unit with high frequency of violent behaviour. Relationships between post traumatic stress symptoms, forensic nursing experience, type of ward and compassion satisfaction, burnout and compassion fatigue were explored.

Results

The prevalence of post traumatic stress symptoms was low. Low scores were found on compassion satisfaction. Length of psychiatric nursing experience and low scores on compassion satisfaction were correlated to increased post traumatic stress symptoms.

Conclusion

Although high violence frequency, low rate of post traumatic stress symptoms and low compassion satisfaction scores was found. High staff/patient ratio and emotional distance between staff and patients are discussed as protective factors.

Workplace violence prevention programs in psychiatric units and facilities

Psychiatric health care providers have high rates of workplace violence victimization, yet little is known about the strategies used by facilities to reduce violence. This study compared workplace violence prevention (WVP) programs in psychiatric units and facilities in California and New Jersey. Information was collected through interviews, a facility walk-through, and a review of written policies and training material. A similar proportion of hospitals in both states had WVP training programs. A higher proportion of hospitals in California had written WVP policies, and a higher proportion of New Jersey hospitals had implemented environmental and security modifications to reduce violence. Legislation is one of many potential approaches to increase workplace violence prevention programs in health care settings.

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.

Reducing inpatient aggression: does paying attention pay off?

OBJECTIVE

Inpatient aggression is poorly documented in official records. Video technology can improve detection, but is labor-intensive and costly. We examined the effectiveness of interventions to improve reporting on a secure inpatient research unit equipped with audio/video surveillance.

METHOD

Systematic review of all video recorded during a six-week period in 2000 revealed that official documentation omitted 16/71 aggressive incidents (23%). Subsequent interventions to improve reporting involved therapy aides, whose jobs entail continuous direct contact with patients. We reviewed the corresponding period in 2005 to investigate changes in aggression and reporting.

RESULTS

Although the number of aggressive incidents did not change significantly, reporting improved: 59/62 (95%) events detected in 2005 had been reported. Physical aggression decreased and verbal aggression increased.

CONCLUSIONS

Improved reporting may have the unanticipated benefit of reducing physical aggression, perhaps by fostering recognition of and intervention in events that might otherwise escalate into more serious aggression.

Forensic psychiatric nursing: skills and competencies: II clinical aspects

This study reports on research undertaken to identify the skills and competencies of forensic psychiatric nurses working in secure psychiatric services in the UK. The rationale for this research is the lack of clarity in the role definition of nurses working in these environments and the specific content that may underscore the curriculum for training forensic nurses. Over 3300 questionnaires were distributed to forensic psychiatric nurses, non-forensic psychiatric nurses and other disciplines and information obtained on (1) the perceived clinical problems that give forensic nurses the most difficulty; (2) the skills best suited to overcome those problems; and (3) the priority aspects of clinical nursing care that needs to be developed. A 35% response rate was obtained with 1019 forensic psychiatric nurses, 110 non-forensic psychiatric nurses and 43 other disciplines. The results highlighted a 'top ten' list of main problems with possible solutions and main areas for development. The conclusions drawn include a focus on skills and competencies regarding the management of personality disorders and the management of violence and aggression.

Forensic psychiatric nursing: skills and competencies: I role dimensions

This paper reports on an investigation into the skills and competencies of forensic psychiatric nurses from the perspective of three groups: (A) forensic psychiatric nurses; (B) non-forensic psychiatric nurses; and (C) other disciplines. A national survey of forensic psychiatric services in the UK was conducted, and information gathered on the perceived skills and competencies in this growing field of psychiatric practice. From 3360 questionnaires, 1172 were returned, making a response rate of 35%. The results indicate a small discrepancy between forensic nurses' and non-forensic nurses' perceptions of the role constructs of forensic practice. However, a larger difference was noted between nurses' perceptions and other disciplines' perceptions of the constituent parts to forensic psychiatric nursing. Nurses tended to focus on personal qualities both in relation to themselves and the patients, while the other disciplines focused on organizational structures both in defining the role and in the resolution of perceived deficits. The findings have implications for multidisciplinary working, as well as policy formulation and curriculum development in terms of the skills and competencies of forensic nurse training.

Workplace violence on workers caring for long-term institutionalized schizophrenic patients in Taiwan

It has been noted that workplace violence most frequently occurs in psychiatric settings. The purpose of this study was to explore the workplace violence, including violence situation, victims' feeling, and the prevention strategies, on workers caring for long-term institutionalized schizophrenic patients in Taiwan. We conducted a face-to-face, in-depth, and semi-structured interview with 13 health care workers suffering from physical violence and/or sexual harassment by patients in 2002. First, the interviews were taped and/or paper-notes recorded, then transcribed, organized, and analyzed. Results found that all of the victims alleged they did not receive enough post-incident support, and more than a half of the victims could not call others for help during the violence. To avoid further attack, most victims offered prevention strategies which were considered valuable for establishing guidelines. However, some victims regarded workplace violence as inevitable and part of the job. The most common situations of workplace violence were during routine ward inspections, especially when the victims were alone. The most serious psychological harm was post-traumatic stress disorder (PTSD). In conclusion, we recommended a re-engineering of the organization to a supportive and safe working environment for prevention of workplace violence in the study hospital.

The psychological impact of aggression on nursing staff

Aggression and violence towards nursing staff in UK health care is a growing problem. While the National Institute for Health and Clinical Excellence's (NICE, 2005a) guidelines 'The Short-Term Management of Disturbed/Violent Behaviour in In-Patient Psychiatric Setting and Emergency Department' offer a way forward in managing aggression for healthcare staff, the psychological impact of aggression remains an area of concern. Post-incident review has been identified as an approach to considering untoward incidents of aggression, yet post-incident support and interventions for staff experiencing the psychological effects of aggression remain inconsistent and curtailed in many areas. This article discusses the care of a nurse who experienced post-traumatic stress disorder as a result of aggression in the workplace. The process of assessment and treatment is presented with underpinning theories of trauma used to illuminate the discussion. Practical use of current recommended treatments of cognitive behavioural therapy and eye movement desensitization and reprocessing is offered as a method of addressing a growing problem in UK health care.

The conceptualization of physical restraint as a nursing-sensitive adverse outcome in acute care psychiatric treatment settings

The occurrence of physical restraint episodes in psychiatric settings is a major public health issue because the therapeutic utility of this form of behavior control has not been substantiated empirically. The purpose of this article was to examine the extant literature to determine if evidence supports the conceptualization of a physical restraint episode as an adverse client outcome that is sensitive to the organization of nursing care in psychiatric settings. An adapted version of the Quality Health Outcomes Model (Mitchell, P. H., Ferketich, S., & Jennings, B. M. (1998). Quality Health Outcomes Model. Image Journal of Nursing Scholarship, 30, 43-46) was used as the conceptual model to guide this inquiry. The databases Cumulative Index to Nursing and Allied Health Literature, Health and Psychosocial Instruments, HealthSTAR/Ovid and Healthstar, Medline, and psychINFO were searched from 1990 to 2005. There are 101 sources in this review. Evidence strongly suggests that a physical restraint episode is an adverse outcome that is sensitive to the organization of nursing care. A systematic exploration of the specific structures and processes of the organization that affect adverse outcomes, such as physical restraint episodes, is lacking in the United States.

Post-traumatic stress disorder following patient assaults among staff members of mental health hospitals: a prospective longitudinal study

BACKGROUND

Violence by patients against staff members in mental health institutions has become an important challenge. Violent attacks may not only cause bodily injuries but can also have posttraumatic consequences with high rates of stress for mental health staff. This study prospectively assessed posttraumatic stress disorder (PTSD) in employees who were severely assaulted by patients in nine German state mental health institutions.

METHODS

During the study period of six months 46 assaulted staff members were reported. Each staff member was interviewed three times after the violent incident, using the Impact of Event Scale-Revised (IES-R), a widely used PTSD research tool, as well as the Posttraumatic Stress Disorder Checklist--Civilian (PCL-C).

RESULTS

In the baseline assessment following an assault by a patient, eight subjects (17%) met the criteria for PTSD. After two and six months, three and four subjects respectively still met diagnosis criteria.

CONCLUSION

A small minority of assaulted employees suffer from PTSD for several months after a patient assault.

The Impact of Patient Aggression on Carers Scale: instrument derivation and psychometric testing

Patient aggression towards carers constitutes a problem for patients and carers alike. Patients' aggressive behaviour often leads to adverse consequences for carers, especially nurses. Various extensive instruments have been developed to measure such adverse effects on carers. The 'Impact of Patient Aggression on Carers Scale' (IMPACS) is a short instrument intended for use in monitoring negative consequences of such incidents. The items of the IMPACS were derived basically from a review of the literature on negative effects of patient aggression on nurses. The IMPACS was administered to a convenience sample of nurses working on 14 psychiatric acute admission wards in the German speaking part of Switzerland. Factor analysis led to the exclusion of three of the original items and to an interpretable three-factor solution with all factors demonstrating eigen values higher than 1. The factors demonstrate moderate to good internal consistency. Canonical correlation analysis using the dimensions of the Maslach Burnout Inventory (MBI) produced a correlation coefficient of 0.457, thus demonstrating external reliability. In spite of some caveats such as possible response bias and the necessity of the investigation of the test-retest stability of the scale this study suggests that the IMPACS is a good measure of adverse effects and thus merits further development.

Patient assault support group: achieving educational objectives

As violence increases in society at large, violence is also increasing in hospitals and other health care facilities. Assault is one of the most serious occupational hazards reported in both public and private hospitals and their outpatient clinics. Despite prevention and intervention measures, experts predict that assault in hospitals will continue to be a serious problem. This paper describes using a support group to decrease the negative consequences to staff that have been assaulted. This paper explores in detail the program content and reactions by member of the group.

Non-somatic effects of patient aggression on nurses: a systematic review

AIM

This paper describes a systematic review of the predominant non-somatic effects of patient assault on nurses. Background. Patient aggression towards nurses is a longstanding problem in most nursing domains. Although reports on the consequences of physical aggression are more numerous, the non-physical effects create much suffering.

METHOD

A systematic review of literature from 1983 to May 2003 was conducted using the Medline, CINAHL, PsychINFO and PSYINDEX databases. Articles from international journals in English or German and reporting at least three non-somatic responses to patient aggression were included.

FINDINGS

The electronic search produced 6616 articles. After application of the inclusion and exclusion criteria, 25 texts from eight countries and four domains of nursing remained. Twenty-eight main effects were found, and these were categorized using a system suggested by Lanza and including bio-physiological, emotional, cognitive, and social dimensions. The predominant responses were anger, fear or anxiety, post-traumatic stress disorder symptoms, guilt, self-blame, and shame. These main effects occurred across most countries and nursing domains.

CONCLUSION

Despite differing countries, cultures, research designs and settings, nurses' responses to patient aggression are similar. Standardized questionnaires could help improve estimations of the real prevalence of non-somatic effects. Given the suffering caused by non-somatic effects, research should be aimed at preventing patient aggression and at developing better ways to prepare nurses to cope with this problem.

The Progression of Holism Into Postgraduate Curricula in Critical Care Nursing

Critical care education is an important part of the professional development of a competent critical care nurse. Interdependence between physiological and psychosocial theories and concepts is a key consideration in the development of critical care educational programs. This multidisciplinary educational framework fosters a deeper understanding of factors contributing to ill health. Establishing a strategic framework where research, education, clinical excellence, and quality assurance are interlinked is central to enhancing the efficacy of patient care outcomes.

Student psychiatric nurses' approval of containment measures: relationship to perception of aggression and attitudes to personality disorder

Difficult and challenging behaviour by inpatients is a feature of acute psychiatric ward life. Different methods are used to contain these behaviours, and there is international variation in which are approved of or used. Previous research suggests that staff attitudes to patients may affect their willingness to use, or choice of, method. The aim of this study was to explore the relationship between approval of containment measures, perception of aggression and attitude to personality disorder. A survey of student psychiatric nurses was conducted, and using three attitudinal questionnaires related to aggression and containment. An association was found between positive attitude to patients and the approval of containment methods that involved nurses being in personal contact with patients. There was evidence that students' attitudes to patients deteriorated over time. The results highlighted the importance of (and linkage between) staffs' feelings of anger and fear towards patients, and their preparedness to use containment measures.

Safer at work: development and evaluation of an aggression and violence minimization program

OBJECTIVE

Aggression and violence are recognized as significant occupational risks for health care staff. A new aggression minimization program for all public health service staff at risk in New South Wales, Australia was developed and evaluated. Twenty-two hours of training was divided into specific modules addressing: general aggression and violence minimization competencies (modules 1 and 4, 10 h); the specific needs of staff working in high-risk environments (module 2, 8 h); and a module for workplace managers and supervisors (module 3, 4 h).

METHOD

Two pilot samples were evaluated: (i) 15 experienced aggression trainers from across New South Wales completed and evaluated a two-day 'train the trainer' program; (ii) 48 experienced health staff completed the four training modules and assessed satisfaction, knowledge and skills acquired, attitudes toward managing aggression and confidence in dealing with aggressive incidents.

RESULTS

Program materials were judged to be highly suitable. Staff were satisfied and increased their knowledge and skills, and evidenced improved attitudes toward working with aggressive patients. A significant increase in staff confidence for dealing with aggressive incidents was also found, with the more modules staff completed the greater their confidence in dealing with aggressive incidents.

CONCLUSIONS

The program may contribute to helping health service industry staff attain a safer workplace.

Cultures of psychiatry and the professional socialization process: the case of containment methods for disturbed patients

Acute mental disorder necessitating admission to hospital is often accompanied by disturbed behaviour that threatens the health of the person concerned or that of those around them. A range of containment methods are used by psychiatric professionals to keep patients and staff safe. These strategies are strongly emotive and attract strong moral valuations, yet differ sharply between countries. This paper reports a study to investigate the relationship between attitudes to these containment methods, and exposure to psychiatric education and practice. It was hypothesized that the culture of psychiatry in the study country would socialise students' views towards the locally dominant pattern of relative evaluations. Nine cohorts of student psychiatric nurses at different stages of their training at one UK University were asked to complete ratings on 11 containment methods. Containment methods fell into five groups, with mechanical restraint and net beds attracting the most severe disapproval. Neither the relative evaluation of methods, nor the intensity of those evaluations, changed systematically with duration of training. The findings support the interpretation that the relative evaluations of psychiatric containment methods are a property of wider national cultures, rather than an isolated tradition of professional psychiatric practice.

Discourses of blame: accounting for aggression and violence on an acute mental health inpatient unit

The English National Service Framework for Mental Health stipulates that the highest quality of health care should be provided for mental health service users in the most efficient and effective manner. Incidents of aggression and violence militate against achieving that goal, yet such incidents are frequently reported in inpatient settings. Traditionally, research in this area has focused on the extent of the phenomenon, the individual characteristics of those involved and precursors to the incident. For the most part the literature reflects a dualistic, perpetrator/victim conceptualisation of incidents. This study aimed to address the lack of research undertaken from a more systemic perspective by examining how all those involved understood and attributed meaning to violent or aggressive situations and how these attributions justified individual perceptions, reactions and actions. Working from the position that all behaviour, including violent behaviour, has meaning to those involved and can be understood, 16 semi-structured interviews were carried out in one mental health unit. Because only one client was both willing and able to give a full account of an incident, we focus here on two incidents in which that client was involved. Discourse analytic techniques were used to examine her account of the two incidents and those of the staff members involved. Participants discussed key themes from the interviews in terms of several dilemmas: whether the violent or aggressive behaviour was 'mad' or 'bad'; predictable or unpredictable; and had resulted from 'personality' or ' mental illness'. The client and staff discourses were strikingly similar and in each case the central concern was with the attribution of blame. The findings have implications for the professional discourse of mental health care, including the discourse of the current policy agenda, a discourse itself constructed with the primary function of exoneration from and attribution of blame.

Perceiving risk in dangerous situations: risks of violence among mental health inpatients

BACKGROUND

Violence in British psychiatric hospitals appears to be escalating, with nursing staff the most frequent victims of assault. There is also public concern about violence on the part of individuals with mental health problems. In this climate, assessing a patient's risk of violent behaviour has become an important part of mental health care. However, little research has been published into how mental health nurses undertake such assessments in their day-to-day clinical practice.

AIM

The study focused on how mental health nurses make assessments of risk in clinical crisis situations where there is a perceived likelihood of imminent violence. The study sought to identify skills, cognitive processes or any other mechanisms which nurses draw upon to assist in such assessments.

METHOD

Ten experienced mental health nurses working in a secure mental health environment were interviewed and data generated was analysed using a grounded theory approach. An in-depth literature search was also undertaken.

FINDINGS

It was found that, in their risk assessments, nurses rely extensively on their personal knowledge of their patients (in particular, previous history of violent behaviour; biographical data; and impact of the mental health problem on violent behaviour). Nurses 'tune in' to potentially violent situations by observing a scenario as a whole, as well as specific aspects of a patient's behaviour, whilst also searching for causes of the violent behaviour. In making clinical risk assessments, nurses often make rapid, intuitive judgements in which various possibilities are considered regarding the likelihood of violent behaviour (such as the capacity and capability of a patient to be violent and the potential in the situation). It was also found that the ability to intervene successfully in potentially violent situations reduced the level of risk that nurses felt exposed to, and here nurses draw on their knowledge of a particular patient. They also perceive lower levels of risk when working in a skilled team.

CONCLUSION

The study indicates that the development of nurse-patient relationships and working in a supportive team are perceived as protective factors against risk. Implications of the research are discussed in relation to nurse-patient relationships, particularly in the context of the current nursing climate and the way in which violent behaviour may lead to an erosion of these relationships. The importance of 'working in a team' is discussed, as is the consequence of the findings for education and development. Methodological limitations of the study are also discussed.

The Legacy of Violent Attack: An Exploratory Study of Occupational Therapy Students' Experiences of Violent Attack

This study aimed to develop an understanding of occupational therapy students' experiences of violent attack by a client. A qualitative approach was chosen, which involved semi-structured interviews with three students and an analysis of the researcher's experience of violent attack.

A wide variety of reactions to violent attack by a client was reported, including fear, anger, concern for others, minimisation and thoughts about changing career. The explanations for these reactions are reported and discussed. The participants reported changes in their therapeutic relationships with clients. The findings also suggested that there might be some occupational therapy personnel who feel that violence is ‘part of the job’.

Three key issues are discussed: the nature of the reactions to violent attack, the perceptions of role and the therapeutic relationship with the client. It is suggested that these findings have important implications for the education and training and the support of occupational therapy students. Recommendations are made regarding the need for further research to inform the way forward in training and supporting those experiencing violence in clinical practice settings.

The impact on work-related stress of mental health teams following team-based learning on clinical risk management

Risk management is viewed as a systematic process based on multiprofessional and multi-agency decision-making. A learning pack was developed as part of a team-based learning project aiming to encourage and develop collaborative working practice. This brought different professionals and agencies working in mental health together to learn. There is little doubt that mental health practice is a source of stress for practitioners. Apart from the stress associated with managing 'risky' situations, risk management is also a relatively new concept. This can increase stress around ability to cope, both on an individual practitioner level and in teams. This article reports the impact that the learning pack had on team members' stress, specifically work-related stress. A range of scales were used to measure change in stress and results demonstrated reduced work-related pressure in a number of areas following the learning. The implications for team learning in relation to clinical risk management are discussed in light of the findings.

The lived experience of violence in accident and emergency

AIM

To investigate the lived experience of violence of nurses in one A&E department.

RATIONALE

Following an extensive literature review, it was elicited that there was very little evidence of the psychological impact of violence in A&E.

BACKGROUND/INTRODUCTION

Violence in the health service has increased over the last decade associated with a corresponding increase in the published literature on this topic. While violence in A&E departments would appear common, little evidence exists on the psychosocial impact of these incidents on A&E nurses.

RESEARCH METHODS

A qualitative domain using a phenomenological philosophy was utilised. Sampling was of a volunteer nature and data were collected using interview. Nurses were sampled from one major acute hospital in Northern Ireland.

RESULTS

Participants expressed feelings of frustration, anger, and fear. Support from colleagues was greatly valued and lack of feedback from management was cited as being common.

DISCUSSION

Frustration and anger were synthesised into the "why me" principle with nurses not knowing why they were the focus for attack. Violent incidents were associated with a sense of isolation but colleague support developed a sense of belonging.

CONCLUSIONS

Whilst a useful insight was provided, more research is essential into this emotive topic.

How prevalent is violence towards nurses working in general hospitals in the UK?

BACKGROUND

Violence in nursing is not a new phenomenon but in recent years much greater emphasis has been placed on the problem in the United Kingdom (UK). A number of official reports, media stories and national initiatives have focused attention on the problem in this country. However, it is not clear whether violence and abuse have in fact become more prevalent. At present little is known about the scale of the problem for general nurses working in general hospitals in the UK.

AIM OF THE STUDY

A realistic assessment of the scale of this problem should facilitate a meaningful debate about the interventions needed to counter it and support the requests for funding that will be required. This study aimed to establish the utility of existing research findings, to include relevant but previously unused sources and to synthesize the results.

METHOD

A systematic search of the literature pertinent to the aim of the study was followed by a critical review. The focus was on research originating in the UK, including some general research on occupational violence which included data on nurses.

FINDINGS

Overall, the research findings are limited. The best available evidence suggests nurses as a whole do face a high level of risk compared with all workers and this excess risk holds for general nurses. The data support a figure of more than 9.5% of general nurses working in general hospitals assaulted (with or without injury) in any 1 year. Trends over time are impossible to identify at present.

CONCLUSIONS

Efforts to combat the problem should include greater emphasis on the problem outside accident and emergency departments, prioritizing preregistration training in the management of aggression, and further research. Better reporting should also be a priority.

The content of management of violence policy documents in United Kingdom acute inpatient mental health services

AIM OF THE STUDY

The aim of the study was to examine the content of Trust policies concerning the prevention and management of violence in acute in-patient settings in order to establish their usefulness as guidance for staff in this difficult, complex, and controversial aspect of inpatient psychiatric care.

BACKGROUND

Violence is a commonly encountered problem in inpatient psychiatric settings. There are legal requirements for workplaces in general and mental health care facilities in particular to develop safe systems of work based upon the findings of assessments of this risk. Policies have a key role to play in making explicit the responsibilities of both employer and employees, and specifying standards of acceptable practice.

DESIGN

A cross-sectional survey methodology was used, which entailed examination of the content of management of violence policies that had been forwarded to the authors from 40 Trusts providing acute inpatient psychiatric care throughout England, Scotland, Wales, and Northern Ireland.

FINDINGS

Policies were found to vary widely in their content, and serious shortcomings were noted in the extent to which policies included information regarding their status and review, advice on the prevention of violence, the management of violent incidents, and postincident action.

CONCLUSIONS

Further research is needed to tease out the extent to policies which are lacking in content, reflect shortcomings in the organizational approach to the prevention and management of violence by Trusts, and the extent to which such shortcomings result in harm being suffered by staff and/or patients. An alternative format for the presentation of management of violence policies is discussed, and items that should be included in inpatient units' management of violence policies are suggested.

The relationship between support and stress in forensic community mental health nursing

AIMS OF THE STUDY/PAPER: This paper reports the results of a survey of forensic community mental health nurses (FCMHNs) in England and Wales which aimed to ascertain the level of stress and burnout experienced by this group.

BACKGROUND/RATIONALE

Several studies have identified that mental health nursing is a stressful activity and the relationship between factors such as age, experience, support, caseload size and perceived stress have been explored. However, until recently, no studies have examined the situation of FCMHNs and this paper extends the analysis of studies completed by the main author, considering issues related to coping abilities and support systems.

DESIGN/METHODS

The survey involved respondents completing a demographic questionnaire and a range of standardized validated measures (Maslach Burnout Inventory, General Health Questionnaire and Community Psychiatric Nurse Stress Questionnaire). The population for the study was all identified FCMHNs attached to the 26 National Health Service (NHS) Medium Secure Units in England and Wales (n=104).

RESULTS/FINDINGS

A high response rate of 77% (n=80) was achieved. The results identified that a number of respondents were experiencing burnout. Statistically significant associations were found between caseload size and level of stress. The results also suggest that support from managers and colleagues were an important factor in ameliorating the experience of stress and show that individuals in this study experiencing high levels of stress adopted palliative behaviours such as use of alcohol.

CONCLUSIONS

The paper concludes by suggesting that such findings should be considered when delivering stress management programmes and reinforce the potential benefit of effective clinical supervision as a means of staff support.

Community mental health nurses in Wales: self-reported stressors and coping strategies

There is evidence to suggest that community mental health nurses experience stress and burnout related to their work. Previous research has been limited by a number of methodological problems. One of the problems is that studies have tended to have small or unrepresentative samples, and many researchers have only examined mental health nurses as a subset within their research, which limits the generalizability of the findings. The All-Wales Community Mental Health Nurse (CMHN) Stress Study was set up in order to address this issue. The total population of CMHNs in Wales was surveyed (N = 614) and 301 (49%) responded. The questionnaire booklet contained a number of validated instruments to measure stress, burnout, and coping, together with a demographic questionnaire. The demographic questionnaire included three open ended-questions. These questions were asked in order in determine the CMHNs' own views of the sources of stress in the workplace, and to investigate which methods they use to cope. This paper reports the findings from the content analysis of the three questions. The results from the other measures are reported in the companion paper (Edwards et al. 2000). The most frequently cited stressors included perceived workload, excessive paperwork and administration, and a broad spectrum of client-related issues. Coping strategies that CMHNs reported using included peer support, a range of personal strategies such as relaxation, and belief in self and supervision. It appears from the findings that a range of factors such as organizational pressures and factors related to working with patients are important in determining stress levels, and that informal rather than formal support networks are the preferred methods of coping.

Professional nurses' perception of nursing mentally ill people in a general hospital setting

The aim of this study was to explore professional nurses' perception of nursing mentally ill patients in a tertiary hospital in Durban. An explorative, qualitative, descriptive and contextual design was followed as the basis for conducting the study. The above-mentioned research design was achieved through field work conducted in an urban-based general hospital. A sample of 12 professional nurses was selected from a population of 800 professional nurses employed in this setting using a purposive sampling technique. This sample size was determined by saturation of data as reflected in repeating themes. Both individual phenomenological semistructured interviews and field notes in the form of observations were used as methods of data collection. The field work was conducted without any preset theoretical framework of reference by using bracketing and intuiting. During interviews, participants were asked only one research question, namely: 'How do you perceive nursing mentally ill patients in your unit or ward?' Communication skills were employed to encourage participants to verbalize their perception of nursing mentally ill patients in a general hospital setting. A tape recorder was used to collect data and the data was transcribed verbatim. Data collected was analysed following the descriptive method of Giorgi (1986). Coding was carried out by the researcher and an independent expert who is a psychiatric nursing specialist and a qualitative research expert. After data analysis, the results were reflected within universal categories of the Nursing for the Whole Person Theory in order to give them structure. The four themes that emerged from the findings are: perception of self, perception of a patient, perception of feelings that hinder nursing the mentally ill, and perception of the environment. The measures for ensuring trustworthiness proposed by Guba (Lincoln Y.S. & Guba E.G. (1985) Naturalistic Inquiry. Sage, Beverly Hills) were used as the basis for ensuring reliable and valid findings. The perception of nursing mentally ill people within a general hospital setting was negative and affected the intellectual and the affective component of the nurses' psychological functioning within their internal environment. It was recommended that nurses' knowledge and skills should be increased and that they should be given emotional support in terms of counselling.

Supporting nursing staff exposed to violence at work

An individual nurses risk of experiencing violence will vary related to his or her area of practice, role and work setting. The available evidence suggests that good practice in environmental design, security management and staff training may reduce but will not eliminate the probability of nurses experiencing assault. If we cannot prevent all violence then we must consider how we best support those who may be exposed to it. This paper thus explores the research on the effects of violence on nurses and critically examines the literature on staff support.

A European perspective on psychiatric nursing and violent incidents: management, education and service organisation

The topic of violent incidents and its importance to inpatient psychiatric nursing practice is well recognised in the academic literature. However the awareness and profile of the issue in different European countries is highly variable. In this paper five European countries are compared: Italy, Norway, the Netherlands, Sweden and the UK. Contextual factors are likely to determine the perception, recognition and acknowledgement of the problem. Those described in detail here are the organisation of psychiatric inpatient services, the training of psychiatric nurses, and the methods used by those nurses to control and contain disturbed patients. For each of these factors large variations exist between the countries considered. The conclusion is drawn that there is much scope for useful comparative research.