Towards a model for understanding the development of post‐traumatic stress and general distress in mental health nurses

In their daily work, mental health nurses (MHN) are often exposed to stressful events, including patient‐perpetrated aggression and violence. Personal safety and health concerns, as well as concern for the physical and psychological well‐being of patients, dominate; these concerns have a profound impact on nurses. This cross‐sectional study explored and compared the psychological well‐being of 196 hospital‐based MHN (97 forensic and 99 mainstream registered psychiatric nurses or psychiatric state enrolled nurses). The aim was to examine exposure to inpatient aggression and work stress, and identify factors contributing to the development of post‐traumatic stress reactions and general distress. Multiple regression analyses indicated that working in a mainstream setting is associated with increased work stress; however, mainstream and forensic nurses experienced similar psychological well‐being. As a group, 14–17% of mainstream and forensic nurses met the diagnostic criteria for post‐traumatic stress disorder, and 36% scored above the threshold for psychiatric caseness. A tentative model of post‐traumatic stress and general distress in nurses was developed, illustrating the impact of aggression and stress on well‐being. The present study affirms that mental health nursing is a challenging and stressful occupation. Implications for organizations, managers, and individual nurses are discussed.     

Aggressive and violent incidents: perceptions of training and support among staff caring for older people and people with head injury

Background. Reported rates of workplace violence are increasing and studies of violence and aggression to health service staff in the United Kingdom have largely focused upon mental health and accident and emergency units. The study of violence and aggression in other specialties has been neglected. This paper reports the findings from a survey of staff perceptions of training and support in an elderly care and head injury unit. Aims and objectives. Staff in a care of older people and head injury unit, half of whom were nurses, were surveyed to identify their experiences of violence and aggression in the workplace, their receipt of training, the relevance of training and knowledge of support services. Methods. An anonymous semi‐structured questionnaire was sent to all nursing, therapy and psychology staff in the unit. Quantitative data were analysed by SPSS and content analysis was adopted for the qualitative data. Results. Just over half the participants had experienced an incident of violence or aggression in the past 12 months. Training was judged to be relevant by almost 90% of respondents but was not always delivered in line with trust guidance. Staff who had been involved in incidents were more likely to identify training needs. A higher percentage of nurses than other professions were involved in incidents, but they were not as aware of the staff support department as other professional groups. Conclusions. The findings indicate that care of older people and head injury units should examine more closely the delivery of staff training on violence and aggression, and invite staff to identify their training needs. A national survey of approaches to staff support may be worthwhile. Relevance to clinical practice. Staff who had received training judged it to be relevant to their working situations, but outstanding training needs should be identified and addressed. Confidential staff support facilities should be well publicized.     

The effect of a training course on mental health nurses' attitudes on the reasons of patient aggression and its management

Aggression in healthcare systems poses a major problem for nurses because they are the most susceptible to suffer violence. Studies demonstrate that attitudes of nurses influence their behaviour regarding aggression and violence. Training programmes can positively change nurses' attitudes. This quasi-experimental study aimed to examine the effects of a systematic training course in aggression management on mental health nurses' attitudes about the reasons for patients' aggression and on its management. Sixty-three nurses (29 in the intervention and 34 in the control group) participated in this quasi-experimental pre-test and post-test study. The attitude of the participants of a training course was recorded by the German version of the Management of Aggression and Violence Attitude Scale (MAVAS). No significant attitude changes occurred in the intervention group at post-test. It is concluded that trainings intending to influence attitudes regarding the reason for patient aggression should consider the impact of the pedagogical quality of the training course, organizational support, and the user's perception. Moreover, it remains questionable to what extent a single instrument of measurement can record attitude changes.     

Mental health nursing practice in rural and remote Canada: Insights from a national survey

Access to and delivery of quality mental health services remains challenging in rural and remote Canada. To improve access, services, and support providers, improved understanding is needed about nurses who identify mental health as an area of practice. The aim of this study is to explore the characteristics and context of practice of registered nurses (RNs), licensed practical nurses (LPNs), and registered psychiatric nurses (RPNs) in rural and remote Canada, who provide care to those experiencing mental health concerns. Data were from a pan-Canadian cross-sectional survey of 3822 regulated nurses in rural and remote areas. Individual and work community characteristics, practice responsibilities, and workplace factors were analysed, along with responses to open-ended questions. Few nurses identified mental health as their sole area of practice, with the majority of those being RPNs employed in mental health or crisis centres, and general or psychiatric hospitals. Nurses who indicated that mental health was only one area of their practice were predominantly employed as generalists, often working in both hospital and primary care settings. Both groups experienced moderate levels of job resources and demands. Over half of the nurses, particularly LPNs, had recently experienced and/or witnessed violence. Persons with mental health concerns in rural and remote Canada often receive care from those for whom mental health nursing is only part of their everyday practice. Practice and education supports tailored for generalist nurses are, therefore, essential, especially to support nurses in smaller communities, those at risk of violence, and those distant from advanced referral centres.     

Evaluating the impact of an electronic application of the Dynamic Appraisal of Situational Aggression with an embedded Aggression Prevention Protocol on aggression and restrictive interventions on a forensic mental health unit

Risk assessment is a pre‐requisite for violence prevention in mental health settings. Extant research concerning risk assessment and nursing intervention is limited and has focused on the predictive validity of various risk assessment approaches and instruments, with few attempts to elucidate and test interventions that might prevent aggression, and reduce reliance on coercive interventions. The integration of risk assessment and violence prevention strategies has been neglected. The aim of this feasibility study was to test a novel Aggression Prevention Protocol designed to prioritize the instigation of less restrictive interventions on an acute forensic mental health unit for female patients. A prospective quasi‐experimental study was designed to test an Aggression Prevention Protocol, linked to an electronic application of the Dynamic Appraisal of Situational Aggression (DASA). Following introduction of the DASA and Aggression Prevention Protocol, there were reductions in verbal aggression, administration of Pro Re Nata medication, the rate of seclusion, and physical and mechanical restraint. There was also an increase in documented nursing interventions. Overall, these results support further testing of the electronic application of the DASA and the Aggression Prevention Protocol.     

The Management of Aggression and Violence Attitude Scale (MAVAS): a cross-national comparative study

Title.  The Management of Aggression and Violence Attitude Scale (MAVAS): a cross-national comparative study.
Aim.  This paper is a report of a study to determine the transferability of the Management of Aggression and Violence Attitude Scale to European mental health inpatient settings.
Background.  Incidents of patient aggression and violence are common in psychiatric in-patient facilities, and nurses' attitudes may play a part in how they are managed.
Methods.  Nursing staff from acute psychiatric in-patient units in Switzerland and the United Kingdom completed the Management of Aggression and Violence Attitude Scale. Data were collected in the UK in 2001 and Switzerland in 2003. The Swiss sample comprised 75 respondents: 45 female, mean age 36·24, mean experience 7·35 years, 60 Registered Nurses. The United Kingdom sample was 75 respondents: 58 female, mean age 32, mean experience 5·25 years, 48 Registered Nurses. T -tests identified differences between the groups in their responses to each Management of Aggression and Violence Attitude Scale statement.
Results.  There was 66% concordance of views between the groups. Swiss nurses were, however, more likely to regard factors internal to the patient as contributory to aggression while United Kingdom nurses perceived environmental factors to be more important. Both groups endorsed physical means of aggression management, Swiss nurses more so.
Conclusion.  There are both commonalities and differences between the attitudes of Swiss and United Kingdom nursing staff regarding patient aggression. Differences may relate to rates of aggression, variations in management approaches, training and policy. The Management of Aggression and Violence Attitude Scale is a potentially effective tool for making comparisons about perspectives on patient aggression.     

The nurse's role in the management of aggression

Although research into the phenomenon of aggression within psychiatric inpatient settings has established a strong casual link with mental illness, there is widespread agreement that diagnostic or demographic characteristics cannot accurately predict such behaviours. In addition, studies have consistently failed to establish how nursing management responses influence the course of aggression within these environments. Therefore, an assumption can be made that specific contextual factors are significant, and that management responses have an effect on outcomes. This review examines the nurses' impact on inpatient aggression and how management strategies affect the therapeutic value of intervention.     

Nurses under threat: a comparison of content of 28 aggression management programs

Staff who work in the health service are now recognized as a high-risk group for assault in the workplace. Recently, professional and industrial organizations have begun to suggest appropriate curricula for training staff in aggression management. However, there is currently a plethora of aggression management training programs (AMP) available, varying both in content and in duration. In this paper, 28 programs were evaluated against 13 major content areas derived from the recommendations made from key professional and industrial organizations, and what may be today considered appropriate/ideal content areas for AMP. Information on programs available in English was sought via standard databases, the Internet, program providers, and through networking with colleagues and professional organizations. The majority of the programs reviewed covered personal safety issues for staff and patients, together with legal issues. The use of restraint, pharmacological management of aggression and seclusion were features of programs specifically addressing the needs of health care staff in mental health settings. Most programs appeared not to address the psychological and organizational costs associated with aggression in the workplace. This is surprising since the literature suggests that the effects of violence are wide and varied, including increased absenteeism and sick leave, property damage, decreased productivity, security costs, litigation, workers' compensation, reduced job satisfaction together with recruitment and retention issues. Also, few programs were based on a systematic evaluation of their outcomes. Suggestions for program development and their teaching are discussed.     

De-escalating aggression and violence in the mental health setting

Aggressive and violent incidents in the health-care setting are increasing phenomena around the world. The evidence from current literature suggests that changes in health-care access, nursing staff shortages and patient acuity are some of the possible causes. De-escalation is a valuable intervention that can be used by nurses to help counter the growing problems of aggression and violence. The de-escalation project, discussed in the present paper, aimed to explore de-escalation as an important therapeutic process and is an event of considerable potential in the management of aggression and violence. While de-escalation is not a new tool, particularly in the mental health-care setting, an educative programme aimed at renewing nurses' knowledge and skills in de-escalation is a timely project. The final de-escalation kit included a large glossy poster, a nursing staff survey, an in-service education session and a literature-based discussion paper. The de-escalation kit can be of considerable benefit to those nurses who are transient within the workplace, such as casual and agency nurses.     

Evaluating a management of aggression unit for student nurses

BACKGROUND: Workplace violence is acknowledged as a major problem in health care settings and affects staff morale, recruitment, retention and direct health care budgets. Staff training is advocated as the appropriate managerial response, but identifying appropriate training and trainers is difficult and there is little published evidence of training effectiveness. Student nurses are frequent targets of aggression but are less likely to receive specific training. AIMS: The study considered the application of a model of learning to a 3-day learning unit for diploma-level student nurses on the "prevention and management of aggression". It aimed to measure student outcomes of the unit and gain information about more general issues in evaluating training effectiveness. METHODS: A repeated measures longitudinal design was used to obtain data from three cohorts of student nurses (3 x 80 approximately) at four time points over an 8-month period. A questionnaire was administered twice before the unit, at its conclusion and approximately 3 months afterwards, following two clinical placements. RESULTS: Statistically significant changes were demonstrated in a number of areas, including number of risk factors identified, and five "factors" identified from the questionnaire statements. STUDY LIMITATIONS: The results refer to one course for student nurses that had many common elements with popular training courses for qualified staff, including inter-personal and breakaway skills. However, restraint skills were not included. CONCLUSIONS: It is possible to provide training that produces desirable, statistically demonstrable and durable change in knowledge, behaviour, attitudes and confidence using a rigorous longitudinal evaluation research design.     

An evaluation of staff and patient views of and strategies employed to manage inpatient aggression and violence on one mental health unit: a pluralistic design

Following an initial springboard study, a further more extensive piece of research was conducted to identify and evaluate approaches used to manage patient aggression and violence on three acute mental health wards. Data were gathered using an incident form, a questionnaire and interviews. The views of patients (n = 80), nurses (n = 72) and medical staff (n = 10) were explored. Findings revealed a clear distinction between the way staff and patients view both the problem and the response. Patients' view present staff approaches as 'controlling' and believe that environmental and poor communication factors underpin aggressive behaviour. Staff, conversely, attribute aggressive behaviour to internal patient and external factors, which may explain the reason for approaches used. A strong correlation was found between type of patient aggression and response (r = 0.36, P < 0.000) and a high percentage of incidents reported were of an aggressive, as opposed to violent, nature. For example 70% of incidents involved verbal abuse or threat. Despite this, 47% (n = 103) of approaches incorporated the use of medication, restraint or seclusion. These are commonly referred to as traditional methods. Patients clearly view this controlling style as a part of the problem and an emphasis upon control and symptom reduction may be inappropriate given the type of aggression encountered. Key issues were further analysed using an internal, external and situational model, each of which endeavour to explain reasons for patient aggression from different perspectives. It is this emphasis upon sole perspectives that may both contribute to and result in the use of a limited number of management approaches adopted in practice. The integration of all three models to examine the complex nature of patient aggression and violence from a variety of perspectives may be the way forward. As a result, approaches to deal with this problem could be more meaningful and subsequently effective.     

Who would want to be a nurse? Violence in the workplace – a factor in recruitment and retention

In a climate of a declining nursing workforce where violence and hostility is a part of the day-to-day lives of most nurses, it is timely to name violence as a major factor in the recruitment and retention of registered nurses in the health system. Workplace violence takes many forms such as aggression, harassment, bullying, intimidation and assault. Violent acts are perpetrated against nurses from various quarters including patients, relatives, other nurses and other professional groups. Research suggests that nurse managers are implicated in workplace violence and bullying. Furthermore, there may be a direct link between episodes of violence and aggression towards nurses and sick leave, burnout and poor recruitment and retention rates. This paper explores what is known about workplace violence as it affects nurses, and calls for managerial support and policy to act to improve work environments for all nurses.     

Should nurses restrain violent and aggressive patients?

Violent and aggressive behaviour towards nurses is common, especially in mental health settings. This article explores the value and safety of existing approaches to dealing with violence and aggression, including the use of physical restraint and medication. It highlights the need for greater preventive and participatory measures, and the use of less reactive strategies, such as advance directives.     

Changing practice using recovery‐focused care in acute mental health settings to reduce aggression: A qualitative study

Consumer aggression is common in acute mental health settings and can result in direct or vicarious psychological or physical impacts for both consumers and health professionals. Using recovery‐focused care, nurses can implement a range of strategies to reduce aggression and empower consumers to self‐regulate their behaviour, when faced with challenging situations, such as admission to the acute care setting. Currently, there is limited literature to direct nurses in the use of recovery‐focused care and how it can be used to reduce consumer aggression. Twenty‐seven mental health nurses participated in this study. The constructivist grounded theory method guided data collection and analysis to identify categories that accurately described participants’ experiences. Five categories emerged that described how nurses can implement recovery‐focused care clinically to reduce the risk of consumer aggression: (i) identify the reason for the behaviour before responding; (ii) being sensitive to the consumer's trigger for aggression; (iii) focus on the consumer's strengths and support, not risks; (iv) being attentive to the consumer's needs; and (v) reconceptualize aggression as a learning opportunity. As the importance of promoting consumer recovery is now embedded in mental health policies internationally, nurses need to prioritize the application of recovery‐focused care clinically. Further research to provide evidence‐based outcomes supporting the use of recovery‐focused care is needed.     

Survival of the fittest, or socially constructed phenomena? Theoretical understandings of aggression and violence towards nurses

Violence is an issue that is attracting increasing attention in the nursing literature. There is general agreement that nurses are exposed to unacceptable levels of violence and aggression in the workplace, and that levels of violence are increasing. Despite this attention and awareness, however, violence does not have a standard definition, and theoretical explanations of violence are seldom considered when discussing it in relation to nursing. This paper discusses current issues associated with defining violence, and presents an overview of some of the traditional and contemporary theories of aggression and violence in relation to nursing and the health context. Conflicting issues surrounding predictors and precipitators of violence are examined. We explore the notion that violence is 'part of the job' in nursing. In conclusion, we assert that the current discourses on aggression and violence maintain the status quo, and argue that new explanatory positions on aggression and violence towards nurses are needed.     

Views of nursing staff on the use of physical restraint

A postal questionnaire survey was employed in regional secure and psychiatric intensive care units in England and Wales, in respect of mental health nurses' training in the use of physical restraint. The nurses' views were sought relating to their last experience of implementing the procedure. Whilst most nurses (n = 259, 96.3%) reported positive outcomes in so far that the incident was brought under control, the views of the aftereffects of the procedure were of concern and ambivalence. The literature suggests that service users did not necessarily hold the same positive views. A range of alternatives, which were consistent with the literature, was made by staff to improve intervention in the management of violence. Negative aspects relating to the use of physical restraint were also highlighted. They included procedural, injury, clinical and management issues. Some respondents also expressed concerns about the negative attitudes of their colleagues. The findings of this aspect of the survey highlights that the therapeutic value of physical restraint can only be achieved with appropriate monitoring and with emphasis on psychological intervention in the prevention and management of violence.     

What general emergency nurses want to know about mental health patients presenting to their emergency department

This paper presents the findings of a qualitative project conducted to investigate the education and training requirements that non-mental health trained emergency nurses need to enable them to effectively care for psychiatric patients presenting to a West Australian emergency department. Non-mental health trained nurses are ill-equipped in their psychiatric knowledge, assessment and communication skills to provide best possible care to the one in ten patients presenting to the emergency department with a complex mental health issue. The area of assessment and management of mental health patients in the emergency department is a complex one and staff are required to assess, triage and manage these patients appropriately. Furthermore, with aggression and violence increasing, emergency department nurses are concerned about their safety in the workplace. Focus groups with emergency nurses and semi-structured interviews with subject matter experts were conducted at one West Australian teaching hospital. The findings of the project demonstrated that these nurses considered that customer focus, workplace aggression and violence, psychiatric theory, mental health assessment and chemical dependence as key learning areas. These findings will form a platform for further education and training for ED staff.